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CONTRIBUTORS. 



ATKINSON, JAMES P., A.B., M.S. 

BAKER, S. JOSEPHINE, M.D., D.P.H. 

BERRY, CHARLES WHITE, M.D., D.P.H. 

BOLDUAN, CHARLES F., M.D. 

BOWLES, JAMES T.-B., B.S. 

COFER, LELAND E., M. D. 

CONNOR, M. E, M.D. 

DODD, W. L. 

DUNHAM, EDWARD K, M.D. 

FISK, EUGENE LYMAN, M.D. 

GODDARD, HENRY H., A.B., A.M., Ph.D. 

GUILFOY, WILLIAM H., P.S., M.D., D.P.H. 

GUERARD, ARTHUR R., M.A., B.Sc, M.D. 

HARRIS, LOUIS L, D.P.H., M.D. 

HESS, ALFRED F., A.B., M.D. 

HOCH, AUGUST, M.D. 

KRUMWIEDE, CHARLES, M.D. 

MANHEIMER, W. A., B.S., A.M., Ph.D. 

OVERTON, FRANK, M.D., D.P.H. Sc.D. 

PARK, WILLIAM HALLOCK, M.D. 

SOPER, GEORGE A., Ph.D. 

VEILLER, LAWRENCE 

WINSLOW, C.-E. A., Dr.P.H. 

WYNNE, SHIRLEY W., M.D. 



UBLIC HEALTH AND 
HYGIENE 

IN CONTRIBUTIONS BY EMINENT AUTHORITIES 



EDITED BY 

WILLIAM HALLOCK PARK, M.D. 

i » ) 

PROFESSOR OF BACTERIOLOGY AND HYGIENE, UNIVERSITY AND BELLE VUE HOSPITAL MEDICAL 

COLLEGE, AND DIRECTOR OF THE BUREAU OF LABORATORIES OF THE DEPARTMENT 

OF HEALTH, NEW YORK CITY 



ILLUSTRATED WITH 123 ENGRAVINGS 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1920 






^ 

nv 



Copyright 
LEA & FEBIGER 

1920 



OCT 30 1920 



©CU601276 



PREFACE 



A remarkable advance has taken place, in the past few years, in 
the appreciation of the people and of their officials in regard to the 
value of public health. This growing opinion that public health is to a 
large extent purchasable by effort and money, and that it is worth 
purchasing has stimulated health authorities to develop their oppor- 
tunities and to assume greater responsibilities. The best medical 
colleges have felt the force of this public opinion and no longer confine 
their teaching almost wholly to subjects dealing with the diagnosis 
and treatment of disease, but give thorough courses in hygiene, and 
its practical application in preventive medicine. The technological 
schools are also providing similar courses to their students who are 
thinking of entering the field of public health work. The great 
advances in our knowledge concerning hygiene and the increasing scope 
of public health work have led to the creation of many subdivisions 
and the problems and practices connected with these have become so 
highly technical as to require public health workers to restrict their 
activities to special lines. The medical officer for some time has 
appreciated this. AYherever the community is large enough to afford 
it, he has obtained the service of specialists to administer and develop 
the different departments. Thus it has come about that the depart- 
ment of health of any progressive State or large city has under the 
administrative head a number of bureaus dealing with such subjects as 
child hygiene, industrial hygiene, mental hygiene, sanitary inspection, 
foods, communicable diseases, hospitals, vital statistics, public health 
education and laboratories. Each of these divisions is placed under 
some specialist who has demonstrated his fitness. 

The time has passed when any one person can possess the technical 
knowledge and personal experience required properly to direct and 
develop all or even several of these different branches of public health 
work. It is also true that few if any persons can discuss authorita- 
tively more than one. or two of these subjects. The report of the 
American Public Health Association on the control of communicable 
diseases was consulted in writing the chapter on that subject. 



vi n PREFACE 

The writers of this hook, holding the above opinions, believed that 
there was need of a volume in which the most important phases of 
hygiene in relation to public health would be presented in a practical 
way by specialists actually devoting themselves to the subjects treated 
by them. The writers have kept in mind that the book is intended for 
public health officials, physicians and medical students, and each has 
therefore tried to make his section as practical as possible and to utilize 
to the full his own personal experience. For this reason it has been 
impractical in most instances to give credit for the original sources of 
information embodied in the articles. 

Xo attempt has been made in this volume to treat the subjects of 
public health law and administration as these do not fall within its 
scope. Other subjects more or less related to public health have been 
omitted because of the necessity of drawing the line somew T here in 
order not to increase too greatly the size of the book. 

The editor was assisted in the early development of the book by 
Dr. Caroline E. Rosenberg. She was called away to service in Europe 
and since then he has been helped by Dr. Edward H. Marsh who has 
also prepared the index. He wishes to express his appreciation of their 
help. 

W. H. P. 

New York, 1920 



CONTRIBUTORS. 



JAMES P. ATKINSON, A.B., M.S. (Princeton), 

Chief Chemist to the Department of Health of the City of New York; formerly 
Research Chemist to the Bureau of Laboratories in the Department of 
Health, City of New York. 

S. JOSEPHINE BAKER, M.D., D.P.H., 

Director of the Bureau of Child Hygiene, Department of Health, New York 
City; Lecturer on Child Hygiene at Teachers' College, Columbia Uni- 
versity and New York University and Bellevue Hospital Medical College; 
Consultant in Child Hygiene, U. S. Public Health Service; Former Presi- 
dent of the American Child Hygiene Association; Member of the American 
Medical Association; Fellow of the New York Academy of Medicine. 

CHARLES WHITE BERRY, M.D., D.P.H., 

Lecturer on Military Hygiene in the New York University and Bellevue 
Hospital Medical College, New York City; Lecturer on Preventive 
Medicine in the Long Island Medical College, Brooklyn, N. Y., and the 
Post-Graduate School, New York City; Fellow of the New York Academy 
of Medicine, The American Public Health Association and the American 
Medical Association; Brigadier-General, New York National Guard; 
Adjutant-General of the State of New York. 

CHARLES F. BOLDUAN, M.D., 

Lecturer on Preventive Medicine and Hygiene in the College of Physicians 
and Surgeons (Columbia University), New York; Chief of the Section of 
Public Health Education in the U. S. Public Health Service, Washington, 
D. C. 

JAMES T.-B. BOWLES, B.S. (Univ. of Mich.), 

Lecturer in Water Supply and Sewage Disposal at New York University, 
Department of Hygiene, Bellevue Hospital Medical College; formerly 
connected with the University of Wisconsin in the Study and Inspection 
of Water Supplies, Municipal Sewage Disposal Plants and Disposal of 
Creamery Waste; in charge of Water Supplies and Purification Plants, 
Canal Zone, Panama; Sanitary Expert with Expeditionary Forces, Vera 
Cruz, Mexico; Formerly Lieut.-Col., Sanitary Corps, U. S. Army; Advisor 
on Water Supplies and Sewage Disposal. 

LELAND E. COFER, M.D., 

Surgeon, U. S. Public Health Service; Health Officer of the Port of New York; 
Member of the Board of Health, New York City. 



x CONTRIBUTORS 

M. B, CONNOR, M.D., 

Medical Department, U. S. Army, 1901-1904; Health Officer, Panama Canal, 
1904-1914; Superintendent of the Medical Department, United Fruit Co., 
Tela. Honduras, 1914-1916; Superintendent of the Medical Department, 
South American Development Co., 1916; Senior State Director, Interna- 
tional Health Board. 

W. L. DODD, 

Assistant Director of the Department of Sanitation of the Pease Labora- 
tories, New York City; sometime Assistant Departmental Director of 
the Department of Biological Manufacturing, Park, Davis & Co., Detroit, 
Mich.; sometime Lecturer on Bacteriology and Sanitation in the Women's 
Hospital, Detroit, Mich.; sometime Field Bacteriologist and Sanitarian 
Delineator "Save the Seventh Baby" Campaign; sometime Sanitarian- 
in-Charge of the Metropolitan Life Insurance Co., New Orleans Sanitary 
Survey; Member of the American Public Health Association and the 
American Statistical Association. 

EDWARD K. DUNHAM, M.D., 
Lt.-Col., Medical Corps, U. S. A. 

EUGENE LYMAN FISK, M.D., 

Medical Director of the Life Extension Institute, New York; Fellow of the 
American Medical Association and the New York Academy of Medicine. 

HENRY H. GODDARD, A.B., A.M., PhD., 

Director of the Bureau of Juvenile Research, Columbus, Ohio; formerly 
Director of the Psychological Laboratory of the Vineland Training School, 
Vineland, N. J. 

WILLIAM H. GUILFOY, P.S., M.D., D.P.H., 

Registrar of Records in the Department of Health of the City of New York. 

ARTHUR R. GUERARD, M.A., B.Sc, M.D., 

Lecturer on Social Hygiene in the New York State Department of Health, 
New York City. 

LOUIS I. HARRIS, D.P.H., M.D., 

Director of the Bureau of Preventable Diseases of the City of New York; 
Special Lecturer in the Department of Bacteriology and Hygiene in the 
New York University and Bellevue Medical College, New York; Medical 
Advisor to the Labor Sanitation Conference, Greater New York. 

ALFRED F. HESS, A.B., M.D., 

Clinical Professor of Pediatrics in the New York University and Bellevue 
Hospital Medical College, New York City. 

AUGUST HOCH, M.D., 

Late Director, Psychiatric Institute, Manhattan State Hospital for the 
Insane; late Chief Psychopathologist, Cornell Dispensary, New York. 

CHARLES KRUMWIEDE, M.D., 

Assistant Director of the Bureau of Laboratories; Associate Professor of 
Bacteriology and Hygiene in the University and Bellevue Hospital Medical 
College, New York City. 



CONTRIBUTORS xi 

W. A. MANHEIMER, B.S., A.M., Ph.D., 

Chairman of the Department of Physical Training in the Evander Child's 
High School; Special Researches in Sanitation in the Research Laboratory 
of the New York Department of Health; Secretary of the American Asso- 
ciation for Promoting Hygiene and Public Baths; Vice-President of the 
International Congress on Public Baths, Brussels, Belgium, 1920. 

FRANK OVERTON, M.D., D.P.H., Sc.D., 

Sanitary Supervisor of the New York State Department of Health; Captain 
in the Medical Reserve Corps, U. S. A. 

WILLIAM HALLOCK PARK, M.D., 

Professor of Bacteriology and Hygiene in the University and Belle vue Hospital 
Medical College, New York City; Director of the Bureau of Laboratories of 
the Department of Health, New York City. 

GEORGE A. SOPER, Ph.D., 

Major, Sanitary Corps, U. S. A. 

LAWRENCE VEILLER, 

Secretary of the National Housing Association, New York City. 

C.-E. A. WINSLOW, Dr. P.H., 

Professor of Public Health in the Yale School of Medicine, New Haven, Conn. ; 
Curator of Public Health in the American Museum of Natural History, 
New York. 

SHIRLEY W. WYNNE, M.D., 

Chief of the Division of Statistical Research in the Department of Health 
of the City of New York; Member of the Advisory Committee on Statis- 
tics of the New York Tuberculosis Association. 



. 






I 



CONTENTS 



CHAPTER I. 



RELATION OF MICROORGANSIMS TO DISEASE 17 

By William H. Park, M.D. 

CHAPTER II. 

ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES INDIVIDU- 
ALLY CONSIDERED 32 

By William H. Park. M.D., and Charles Krumwiede, M.D. 



CHAPTER III. 

PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES ... 73 
By William H. Park, M.D. 



CHAPTER IV. 

PRACTICAL USE OF DISINFECTANTS 177 

By William H. Park, M.D. 



CHAPTER V. 

EPIDEMIOLOGY 201 

By George A. Soper, Ph.D. 

CHAPTER VI. 

SANITARY SURVEYS 224 

By W. L. Dodd. 

CHAPTER VII. 

AIR AND HEALTH— VENTILATION 239 

By C.-E. A. Winslow, Dr., P.H. 



XIV CONTENTS 

CHAPTER VIII. 

HOUSING 293 

By Lawrence Veiller. 

CHAPTER IX. 

FOOD 308 

By Edward K. Dunham, M.D. 

CHAPTER X. 

VITAMINES 324 

By Alfred F. Hess, M.D. 

CHAPTER XI. 

THE PRESERVATION AND ADULTERATION OF FOOD ... 328 
By J. P. Atkinson, B.S. 

CHAPTER XII. 

BACTERIAL AND OTHER CONTAMINATIONS OF MILK. THEIR 

RELATION TO PUBLIC HEALTH 347 

By William H. Park, M.D. 

CHAPTER XIII. 

BACTERIAL INFECTIONS AND PARASITIC DISEASES FROM 

MILK, MEAT AND OTHER FOODS 385 

By William H. Park, M.D. 

CHAPTER XIV. 

THE SOIL 397 

By Arthur R. Guerard, M.D. 

CHAPTER XV. 

WATER SUPPLIES AND THEIR PURIFICATION 403 

By James T-B. Bowles, B.S. 

CHAPTER XVI. 

SEWAGE AND WASTE DISPOSAL 428 

By James T-B. Bowles, B.S. 



CONTEXTS xv 



CHAPTER XVII. 



HOUSING AND PLUMBING 443 

By Arthur R. Guerard. M.D. 



CHAPTER XVIII. 

THE SANITATION OF SWIMMING POOLS 459 

By Wallace A. Maxheimer, Ph.D. 

CHAPTER XIX. 

PERSONAL HYGIENE 471 

By Eugexe Lyman Fisk, M.D. 



CHAPTER XX. 

ADDITIONAL PRACTICAL POINTS IN PERSONAL HYGIENE . 499 
By Arthur R. Guerard. M.D. 

CHAPTER XXI. 

MILITARY HYGIENE 519 

By C. W. Berry. M.D. 

CHAPTER XXII. 

RURAL PUBLIC HEALTH WORK 555 

By Frank Oyertox, M.D.. D.P.H.. Sc.C. 

CHAPTER XXIII. 

TROPICAL HYGIENE 5S3 

By M. E. Connor, M.D. 

CHAPTER XXIV. 

INDUSTRIAL HYGIENE . . 602 

By Louis I. Harris. M.D. 

CHAPTER XXV. 

CHILD HYGIENE 668 

By S. Josephixe Baker. M.D., D.P.H. 



XVI CONTENTS 



CHAPTER XXVI. 

SOCIOLOGIC AND ECONOMIC ASPECTS OF DISEASE .... 723 
By Charles F. Bolduan, M.D. 

CHAPTER XXVII. 

PUBLIC HEALTH EDUCATION 736 

By Charles F. Bolduan, M.D. 

CHAPTER XXVIII. 

MENTAL HYGIENE 757 

By August Hoch, M.D. 

CHAPTER XXIX. 

MENTAL DEFECTIVES. PREVENTING AND CONTROLLING 

MEASURES 780 

By Henry H. Goddard, Ph.D. 

CHAPTER XXX. 

MARITIME QUARANTINE 795 

By Leland E. Cofer, M.D. 



CHAPTER XXXI. 

VITAL STATISTICS 805 

By William H. Guilfoy, M.D., and Shirley W. Wynne, M.D. 



PRACTICAL HYGIENE 



CHAPTER I. 

RELATION OF MICROORGANISMS TO DISEASE. 

By WILLIAM H. PARK, M.D. 

The great majority of persons born under civilized conditions would 
enjoy health and live to old age were it not for the invasion of their 
bodies by the pathogenic minute unicellular organisms. It is natural, 
therefore, at the very start to consider their characteristics and the 
reaction of the body to their attack. 

In the production of disease by microorganisms there are four 
main factors involved, viz., on the part of microorganisms, the power 
to elaborate in the body poisons or proteins that may be split by fer- 
ments to yield poisons and the ability to multiply in the cells and 
fluids of the tissues; on the part of the cells of the body, the degree of 
sensitiveness to the poisons of the microbe, and the tendency of the 
cells which have absorbed the poisons to develop substances which 
neutralize similar poisons or attack the invading bacteria or protozoa. 

Xo known variety of microorganisms has, in small numbers, the 
ability to produce enough poison to do appreciable injury in the body. 

To understand the germ factor in the production of disease we must 
recognize the fact that both the body cells invaded and the parasitic 
cells which invade them are living organisms, and that the products 
of the cellular activity of the body act on the microorganisms at the 
same time their products act upon the human cells. Just as there are 
different races and species of animals having dissimilar characteristics, 
there are different races and species among bacteria and protozoa. 
The descendants of both under changing conditions gradually become 
diverse. In fact, the. rapidity of the development of new generations 
of the unicellular organisms allow in them of much quicker changes 
under new conditions than are possible in the higher animals and 
plants. Considering these and other facts, we can readily appreciate 
how the different types of the microorganisms do not grow equally 
well hi every variety of animal, and after discovering that there are 
variations in the properties of the blood from day to day we are not 
surprised that they do not find the body of the same animal always 
equally suitable. The study of bacteria in the more simple and known 
conditions of artificial culture media has shown how extremely sensi- 
2 



18 



RELATION OF MICROORGANISMS TO DISEASE 



tive many bacteria are to slight chemical and other changes. It has 
also been found that conditions which are favorable to multiplication 
may still be unfavorable for the production of toxins or poisons. 

For each variety of bacteria there are special conditions requisite 
for growth, and a temperature, degree of acidity, kind of food, supply 
of oxygen, etc., suitable for one may be utterly unsuitable for another. 
Moreover, when two organisms grow together one may so alter some 
of these conditions as to render unsuitable ones suitable, and vice versa. 

The pathogenic protozoa or the parasitic forms are few in numbers 
compared with the total number of protozoa. They exert their 
harmful action mainly mechanically or by the direct destruction of the 
special host tissue which they find suitable for food. That they may 
produce specific toxic substances has been demonstrated in only two 
instances. But though in general no specific toxins have been shown 
to exist in protozoan forms, or to be excited by them, the fact that 
there is spontaneous recovery from various protozoan infections and 
that a reinfection does not take place soon after, indicates that some 
specific toxins or substances are formed which help to produce immunity. 
Infection through protozoa is often accomplished by means of the 
lower animals acting either as intermediary hosts or as direct carriers 
of the virus. 

Adaptation of Pathogenic Bacteria and Protozoa to Certain Tissues. 
— Parasitic microorganisms have gradually adapted themselves not 
only to certain species of animals, but to certain circumscribed areas 
of the body. Thus, the diphtheria bacilli grow chiefly upon the 
mucous membrane of the respiratory tract, but cannot develop in 
the blood or in the subcutaneous tissues. The cholera spirilla develop 
in the inflamed intestinal mucous membrane, but cannot grow in the 
respiratory tract, blood or tissues. The tetanus bacilli develop in 
wounds of the subcutaneous tissue but cannot thrive on the intestinal 
mucous membranes or on the blood. The malarial parasites on the 
contrary develop in the human body, chiefly in the red blood cells. 

Some microbes find certain regions especially suitable for their 
growth, but under conditions favorable for them are capable of 
developing in other locations. Thus, the typhoid bacillus grows 
most luxuriantly in Pyer's patches and mesenteric glands, but also 
invades the blood, spleen and other regions. The tubercle bacillus 
often remains localized in the apex of a lung or a gland for years, but 
may at any time invade many tissues of the body. The gonococcus 
finds the mucous membrane of the genito-urinary tract most suitable 
for its development, but also frequently is capable of growth in the 
eye and peritoneum and sometimes in the general circulation. The 
pneumococcus develops most readily in the lungs, but also invades 
the connective tissues, serous membranes and the blood. The malarial 
protozoa grows not only in human red cells, but also in the cells of 
the stomach and salivary glands of the mosquito. 

Most of these germs, although ordinarily increasing only in the body 
of man, can be grown on suitable dead material. There are a few 



VARIATIONS IN DEGREE OF VIRULENCE 19 

unicellular organisms which, insofar as we know, find the bodies of 
human beings or animals the only fit soil for their growth. These are 
called strict parasites. 

Adaptation of Microbes to the Soil upon Which They Grow. — Those 
organisms which grow both in living and dead substance vary from 
time to time as to their readiness to develop in any one medium or 
other. As a rule, bacteria grown in any one medium become more 
and more accustomed to that and other media more or less analogous 
to it, while, on the other hand, they are less easily cultivated on media 
widely different from that in which they have developed. 

Manner in Which Microorganisms Produce Injury. — [Microorganisms 
produce serious mechanical injury only when they exist in such enor- 
mous numbers or are bunched together so as to interfere mechanically 
with the circulation of the blood or, together with fibrin, cause minute 
thrombi, and later emboli, which finally produce infarction and 
abscesses in different parts of the body. The injurious effects are 
almost wholly due to the chemical substances contained in the germ, 
which are directly poisonous or after being split by ferments. Some 
portion of the protoplasm of almost every variety of bacteria combines 
with some of the substance of the body cells, and acts as an irritant 
to the tissues. 

The poisonous products can often be separated from the fluid in 
which the organisms have grown, or they can be extracted from the 
microbes. Injected into animals these products cause essentially the 
same cellular lesions as are produced by the organisms when they 
develop in the animal body. The substances contained in or produced 
by the organisms, with few exceptions, attract the leukocytes, and 
when great masses of bacteria die suppuration usually follows. The 
same properties undoubtedly exist also in the poisons developed from or 
by the protozoa. 

Influence of Quantity on Infection. — With pathogenic microbes the 
number introduced has an immense influence upon the probability 
of infection taking place. If a few bacteria are introduced into a 
culture medium containing some fresh human blood or serum, they 
will probably all die because of the presence of sufficient bactericidal 
substance in the blood to destroy them; whereas if a greater number 
is introduced there will be at first a great diminution of these — those 
dying which have combined with the bactericidal substances in the 
serums that neutralize them — and thus the bacteria which survive 
begin to increase and soon multiply enormously. The same is true of 
the parasitic bacteria in the body. A few only gaining entrance, they 
may die; a larger number being introduced, some may or may not 
survive; but if a still greater quantity gams entrance, it is almost 
certain that, unless the individual is immune, there will be some 
surviving members which will begin to proliferate and excite disease. 

Variations in Degree of Virulence Possessed by Microbes. — 
Microbes differ as to the ease and rapidity with which they grow in 
any nutritive substance, as already stated, and also in the amount 



20 RELATION OF MICROORGANISMS TO DISEASE 

of poison they produce. Both of the properties not only vary greatly 
in different members of the same species, but each variety of organism 
may be to a large extent increased or diminished in virulence. The 
septicemic class of bacteria when grown in the body fluids seem gradu- 
ally to develop power to elaborate protective substances in their own 
bodies or produce cells with less substance having affinity for the bac- 
tericidal substances of the blood, and thus become less vulnerable. 

\Vith those bacteria whose virulence is great, a very few organisms 
will produce disease almost as quickly as a million, allowance only 
being made for the short time required for the few to become equal in 
number to the million. At the other extreme of virulence, however, 
many millions may have to be introduced to permit of the development 
of any of the organisms in the body. 

Distinct, again, from that class of bacteria which multiply rapidly 
are those like the tubercle and leprosy bacilli which, while readily 
developing infection, increase more slowly. Here increase of virulence 
is shown, as before, by the production of disease through the intro- 
duction of very small numbers into the body, but increase in rapidity 
of development cannot progress except to within certain limits. A 
single streptococcus may, through its rapid multiplication produce 
death in eighteen hours; a single tubercle bacillus, on the other hand, 
cannot produce sufficient numbers in less than two weeks. 

Experimental Increase and Decrease in Toxicity and Virulence. — 
The power to produce toxin and to infect animals can be taken from 
microbes by growing them under adverse circumstances, such as cultiva- 
tion at the maximum temperature at which they are capable of develop- 
ment, some microbes being easily attenuated, and others being robbed of 
their virulence only with great difficulty. Increase of virulence is more 
difficult and only possible to obtain to a certain extent. The means 
usually employed are the frequent passage of the culture through 
animals. The streptococcus from erysipelas and the pneumococcus 
from pneumonia are typical of this class of organism. With other 
cultures increase in virulence does not take place. The same increase 
can be noted when septic infection is carried in surgical or obstetrical 
practice from one human being to another. 

Mixed Infection. — The combined effects upon the tissues of the 
products of two or more varieties of pathogenic microbes, and also of 
the influence of these different forms on each other, are of great impor- 
tance in the production of disease. The infection from several differ- 
ent organisms may occur at the same time, or one may follow the other 
or others — so-called secondary infection. Thus, an abscess is often due 
to several forms of pyogenic cocci. If a fresh wound is infected from 
such a source the inflammation produced will probably be caused by 
all varieties present in the original infection. Peritonitis following 
intestinal injury must necessarily be due to more than one variety of 
organism. Whenever two or more varieties of bacteria are transferred 
to a new soil, mixed infection is said to take place if more than one of 
these is capable of developing in that locality. 



CHARACTERISTICS INFLUENCING THE GROWTH OF MICROBES 21 

Forms of infection which are both secondary and mixed infections 
are those occurring in the mucous membrane of the respiratory and 
digestive tract. In these situations pathogenic microbes of slight 
virulence are always present, even in health. Thus, in the air pass- 
ages there are usually found streptococci, influenza bacilli and pneu- 
mococci. When through the invasion of one or several infective agents, 
as the diphtheria bacillus or the virus of smallpox or scarlet fever, 
the epithelium of the mucous membrane of the throat is injured or 
destroyed, the pyogenic cocci already present are now enabled in this 
diseased membrane to grow, produce their poisons and even invade 
deeper tissues. The intestinal mucous membrane is invaded in a 
similar way by the colon bacilli and other organisms after injury by 
the typhoid or dysentery bacilli or cholera spirilla. Generally speak- 
ing, all inflammations of the mucous membranes and the skin contain 
some elements of mixed infection. Blood-infection, on the other hand, 
is usually due to one form of bacteria, as even when several varieties 
are introduced, only one as a rule is capable of development. The 
same is true to a somewhat less extent of inflammations of the con- 
nective tissue. The additional poisons given off by the associated 
microbes aid infection by the primary invaders by causing a lowering 
of the vital resistance of the body. In some cases the secondary 
infection is a greater danger than the primary one, as pneumococci 
bronchopneumonia in laryngeal diphtheria, lobar or bronchopneu- 
monia in influenza, or streptococcic septicemia in scarlet fever and 
smallpox. 

Microorganisms are also at times directly influenced by the products 
of associated organisms. They may affect them injuriously as, for 
example, the pyogenic cocci in anthrax; or they may be necessary to 
their development, as in the case of anaerobic bacteria. Tetanus 
bacilli or spores, for instance, would not be able to develop at times on 
wounds were it not for the presence of aerobic bacteria introduced 
with them. Again, it is found that the association of one variety 
with another may increase its virulence. On the other hand, the 
absorption of the products of certain bacteria immunizes the body 
against the invasion of other bacteria, as shown by Pasteur, that 
attenuated chicken-cholera cultures produce immunity against anthrax. 
In intestinal putrefaction harmless varieties of bacteria may be made 
to crowd out dangerous ones. 

Tissue Characteristics Influencing the Entrance and Growth of 
Microbes. — The Skin. — The skin is a poor soil for bacteria and is a 
great protection against the penetration of microorganisms. When 
they do penetrate, it is through some unobserved wound. The bac- 
terial toxins are, when at all, but slightly absorbed through the skin. 
An apparent exception to the above exists in the fact that the pyo- 
genic staph ylo occi and sometimes the streptococci are found upon 
the skin or in it between its superficial cells, exceptional circumstances 
such as wounds or burns being required to allow the organisms to 
penetrate deeper. The cutaneous sweat-glands and the hair follicles 



22 RELATION OF MICROORGANISMS TO DISEASE 

with their appended sebaceous glands, may also permit the entrance 
of infection through various incidents leading to the introduction and 
retention of virulent organisms. 

Subcutaneous Connective Tissue. — Many microbes cannot develop in 
the connective tissue and others produce a milder infection there than 
elsewhere. Some develop rapidly. The tissue fluids have bactericidal 
properties similar to but less in amount than the blood. 

The Mucous Membranes. — The moist condition of the surface of the 
mucous membranes and their frequent contact with irritating sub- 
stances render them liable to microbal infection. Organisms, such 
as the pneumococci and streptococci reproducing themselves in it, 
become somewhat attenuated; the mucous membranes are protected 
by the cleansing action of the flow of the secretions and by its slight 
germicidal effect. In infancy the mucous membranes are readily 
infected by gonococci and later by pneumococci and other bacilli. 
The mucous membranes of the nasal cavity are also somewhat 
cleansed by the flow of the nasal secretions. The deeper portions 
of the nasal cavity are usually the seat of streptococci and other 
bacteria, while the extreme anterior portions contain saprophytic 
bacteria from the air. The mouth of a person in health is cleansed 
by the feebly bactericidal effect of the saliva. When the teeth are 
decayed many varieties of bacteria abound. The bacteria, such as 
the diphtheria bacilli, streptococci, etc., seldom invade the mucous 
membrane of the mouth or tongue. The tonsils with their crypts are 
usually the seat of the pyogenic cocci and are readily infected with the 
diphtheria bacilli and others. 

The Lungs. — Most inhaled organisms which pass the larynx are 
caught in the bronchi. Many of these are gradually removed by the 
ciliated epithelium. Both the alveoli epithelial cells and the leuko- 
cytes which enter the air cells and bronchioles have been shown to 
take up bacteria. The normal lung is, therefore, rapidly freed of 
saprophytic and many parasitic bacteria. When subjected to delete- 
rious influences, such as exposure to cold, the lung tissues may lose 
their protective defences and become subject to infection. 

The Stomach. — The pure gastric juice, through the hydrochloric 
acid it contains, is able to kill most non-sporebearing organisms in 
a short time, but because of neutralization through food, or because 
the microbes are protected in the food, many of them pass into the 
intestines. Tubercle, typhoid, colon and dysentery bacilli, when fed 
by the mouth with food, readily pass beyond the stomach. Perfora- 
tion of the stomach is usually followed by peritonitis, because of the 
irritant effect of the gastric juice and the bacteria which were tem- 
porarily present in the stomach. The gastric juice alters tetanus and 
diphtheria toxins. The toxicity of some poisons, such as the botulinus 
toxins, is not destroyed. The stomach is exceptionally free from bac- 
terial inflammations. 

Intestines. — The bile is feebly germicidal for some organisms, but 
on the whole, the intestinal secretions have little or no germicidal 



DISSEMINATION OF DISEASE 23 

power. The number of microbes increases steadily from the duodenum 
to the head of the colon, and diminishes slightly from the upper to the 
lower end of the colon. The pancreatic juice destroys many of the 
toxic microbal products. The presence of the bacilli of the colon group 
of streptococci, etc., does not often lead to any inflammatory condi- 
tion in the normal intestines of healthy persons. In children suffering 
from the prostrating effects of heat they are apt to excite inflamma- 
tory changes. Even pathogenic bacteria such as the typhoid, dysen- 
tery and tubercle bacilli, may pass through the whole length of the 
intestines without inciting inflammations. Slight lesions aid the 
passage of bacteria to the deeper structures. Tubercle bacilli and 
other pathogenic bacteria may pass through the intestinal wall to the 
lymph and cause distinct infections without leaving any trace of their 
passage. Non-pathogenic protozoa are frequently found in the intes- 
tines, and, in tropical conditions, pathogenic forms are also found. 

Importance of Location of Point of Entry of Organisms. — Most microbes 
cause infection only when they gain access to special tissues and must, 
therefore, enter through certain portals. This fact is of immense 
importance in the transmission or prevention of disease. Thus, for 
example, let us rub very virulent streptococci, typhoid bacilli and 
diphtheria bacilli into an abrasion in the hand. The typhoid bacilli 
produce no lesion, the diphtheria but a very minute infected area, but 
the streptococci may give rise to a severe cellulitis or fatal septicemia. 
Now place the same bacteria in an abrasion in the throat. The 
typhoid bacillus is again harmless; the diphtheria bacillus produces 
inflammation, a pseudomembrane and toxemia and the streptococcus 
causes an exudate, an abscess or a septicemia. Finally, introduce the 
same bacteria into the intestines, and now it is the typhoid bacillus 
which produces its characteristic lesions, while the streptococcus and 
diphtheria bacillus are usually innocuous. 

If we tried in this way all the parasitic organisms in turn we would 
find that certain varieties are capable of developing and thereby excit- 
ing disease only on the mucous membrane of the throat, others of the 
intestines, others of the urethra; some develop only in the connective 
tissues or in the blood ; while others, again, under favorable conditions, 
seem able to grow in or upon most regions of the body. 

Dissemination of Disease. — The spread of infection is influenced by : 
(1) The number of species of animals subject to infection; (2) the 
quantity of the infectious material and the manner in which it is 
thrown off from the body; (3) the resistance of the infectious organism 
to the deleterious effects of drying, light, etc.; (4) the ability or lack 
of ability to grow outside of the infected tissues; and (5) germ carriers. 

The Number of Species of Animals Subject to Infection. — Many 
human infectious diseases do not occur in animals, and many animal 
infections are not found in man. Thus, so far as we know, gonorrhea, 
syphilis, measles, smallpox, typhoid fever, etc., do not occur in animals 
under ordinary conditions; while tuberculosis, anthrax, glanders, hydro- 
phobia, and some other diseases are common to both man and animals. 



24 RELATION OF MICROORGANISMS TO DISEASE 

The Quantity of the Infectious Material and the Manner in which it 
is Thrown off from the Body. — In diphtheria, typhoid fever, cholera, 
pulmonary tuberculosis, septic endometritis, influenza and gonorrhea, - 
enormous numbers of infectious bacteria are cast off through the dis- 
charges from the mouth, intestines and genito-urinary secretions, 
causing great danger of infection. On the other hand, in tuberculous 
peritonitis, streptococcus meningitis and endocarditis, gonorrheal rheu- 
matism, and the like, there is no danger of infection to others, as no 
bacteria are cast off. 

The Resistance of the Infectious Organism to the Deleterious Effects 
of Drying, Light, Etc. — In this case the presence or absence of spores 
is of the greatest importance. The spore-bearing bacilli, such as 
tetanus and anthrax, being able to withstand destruction for a long 
time, retain their power of producing infection for months or even 
years after elimination from the body. The bacteria which form no 
spores show great variation in their resistance to outside influences. 
Some of them, such as the influenza bacillus and the gonococcus, the 
virus of syphilis and hydrophobia, are extremely sensitive; the pneu- 
mococci, cholera spirilla, glanders bacilli, etc., are a little hardier; then 
follow the diphtheria bacilli, and after them the typhoid and tubercle 
bacilli and the staphylococci. Yeasts, moulds and protozoa produce 
resisting spores, which, however, are not as highly resistant as most 
bacterial types. 

The Ability or Lack of Ability to Grow Outside of the Infected Tissues. 
— Such bacteria as the pneumococcus, tubercle, influenza, diphtheria, 
glanders and leprosy bacilli do not develop, so far as we know, outside 
of the body under ordinary conditions. Under exceptional circum- 
stances, as in milk, some may develop. Others, again, such as the 
streptococcus, typhoid and anthrax bacillus, the cholera spirillum, 
and some anaerobes, may develop under peculiar conditions existing 
in water or soil. 

Germ Carriers, (a) Human Carriers.- — In human carriers micro- 
organisms develop in or upon some portion of the skin or mucous 
membrane, either after or before disease, and without infection. As 
complete a knowledge as possible of this saprophytic development 
in man of parasitic microbes is necessary if we are to combat the 
spread of infection. In the superficial layers of the epithelium and 
on the surface of the skin we find the different pyogenic cocci, which 
are capable of infecting a wounded or injured part or causing inflam- 
mation of the glands. Acne, the pustules in smallpox, the pus on 
a burned surface, boils, etc., all come from these pyogenic cocci. In 
surgical cases the skin has to be as thoroughly disinfected as possible 
to prevent the formation of stitch-hole abscesses and wound infection. 

In the secretions of the mucous membranes covering the pharynx 
and nasopharynx there is always an abundance of microbes. In 
experiments carried out in New York City, streptococci and 
pneumococd were found in almost every throat, and even in the 
country they were often present. In the anterior nares there are 



MIC ROB AL AUTO-INFECTION 25 

fewer parasitic bacteria than in the posterior portions. Many other 
varieties of bacteria such as the meningococci and the influenza bacilli 
are probably often present in smaller numbers. In those constantly 
in contact with cases of diphtheria, and in those convalescent from 
diphtheria, virulent bacilli are frequently found in the throat. After 
convalescence from typhoid fever, from 1 to 3 per cent, remain bacillus 
carriers for months or years. The bacilli continue to develop in the 
bile passages and are passed with the feces. Certain pathogenic proto- 
zoa may be carried for some time in the intestines of man. 

(b) Lower Animals. — The lower animals, as a rule, do not retain in 
their bodies bacteria pathogenic for human beings, but as direct 
carriers of bacterial infection they are important factors. Fleas and 
other insects may convey organisms which are simply attached to 
their feet or other surfaces of their bodies. Biting insects, especially, 
such as fleas, ticks, bed-bugs, lice, flies and mosquitoes, are a source of 
danger in protozoan infections more particularly, since these insects 
act as intermediate hosts in these cases. 

Microbal Auto-infection. — When the intestinal canal is impaired or 
its circulation hindered by strangulation, etc., the colon bacilli and 
some other bacteria may penetrate through the injured walls and 
cause peritonitis or general infection. Under certain conditions as in 
the debility due to hot weather, the bacteria in the intestines may 
cause through their products irritation, and in children even serious 
intestinal inflammation. Long after an acute gonorrhea has passed 
gonococci may remain in sufficient numbers to cause a new inflamma- 
tion or produce infection in others. A cystitis may run on chronically 
for years, and then suddenly become acute or spread infection to the 
kidneys. A persistant gonorrheal vaginal infection may lead to a 
gonorrheal endometritis or peritonitis or salpingitis under suitable 
conditions. The staphylococci in the skin and the colon bacilli and 
pyogenic cocci in the fecal discharges may also be carried into the 
bladder and uterus and produce septic infection. Persons carrying 
diphtheria bacilli in their throats or typhoid bacilli in their gall- 
bladder may, under predisposing conditions, develop diphtheria or 
typhoid fever. 

In nearly all cases of infection the products of bacterial growth are 
absorbed into the blood, and along with them a few bacteria also, 
even when they do not reproduce themselves in it. The greater the 
extent of the infection and the more deep-seated it is, the greater is the 
amount of absorption. 

When bacteria are abundant in the blood they become fixed in 
the capillaries of one or all of the organs, especially of the liver, kidneys, 
spleen and lungs, and then directly or by means of the leukocytes, 
which penetrate the capillary walls, they pass into the tissues and 
substance of the organs. They thus reach the lymph channels and 
glands, or gain entrance into the gall-bladder, saliva, etc., or pass 
through the epithelium, as in the alveoli of the lungs; more rarely they 
pass through the kidney tissue into the urine, as in typhoid fever. 



26 RELATION OF MICROORGANISMS TO DISEASE 

Some of the More Important Microbal Poisons. — Toxins. — Any 
poisonous substance formed in the growth of bacteria or other micro- 
organisms is loosely called a toxin, but in the strict sense this term 
should be confined to the extracellular poisons, as these alone have 
the important characteristic of causing the cells of the body affected 
by them to produce antitoxins. 

The different bacterial poisons vary greatly in their characteristics, 
though little is known about their chemical nature except that they 
arc proteins. They may be divided into two groups: (1) Extracellular 
toxins; (2) intracellular toxins. Under extracellular toxins are included 
those varieties of bacteria that excrete in ordinary culture media water- 
soluble, very specific toxic products. Type: bacilli of botulism, diph- 
theria, tetanus. These alone produce toxins. Under intracellular 
toxins are included those varieties of bacteria which possess toxic pro- 
tein substances which are more or less closely bound to the living cell, 
and which are only in a small degree separable in a changed condition 
outside of the body. Type: the bacteria causing cholera, typhoid, 
etc. These are sometimes called endotoxins. Some of these sub- 
stances are only poisonous when split up by specific ferments present 
in the serum or cell fluids. 

Extracellular Toxins. — The properties of the extracellular toxins 
are as follows: They are, so far as we know, uncrystallizable, and 
thus differ from ptomains; they are soluble in water and they are 
slowly dialyzable, through thin membranes but not through thick 
membranes such as are used in refining antitoxins; they are precipi- 
tated along with peptones by alcohol and also by ammonium sulphate; 
if they are proteins they are either albumoses or allied to these; they 
are relatively unstable, having their toxicity diminished or destroyed 
by heat and freezing as well as by chemical manipulation. Their 
potency is often altered in the precipitation practised to obtain them 
in a pure or concentrated condition, but among the precipitants 
ammonium sulphate has but a moderate harmful effect. A remark- 
able characteristic of the group is that they are highly specific in their 
properties and have the power in the infected body to excite the pro- 
duction of antitoxins. The diphtheria and tetanus bacilli are the 
best known extracellular toxin products. 

Intracellular Toxins. — Regarding the intracellular toxins which are 
more intimately associated with the bacterial cell and are produced 
by all bacteria, very much less is known. They are apparently pro- 
teins, and it is probable that their chemical action is somewhat similar. 
They do not produce antitoxins. These bacterial proteins may be 
poisonous originally, or only when split by ferments. 

Ptomains. — Organic bases of a definite chemical composition have 
been isolated from putrefying fluids, meat, fish, old cheese and milk, 
as well as from pure bacterial cultures (Neuchi, Breyer, Vaughan). 
Some of these have been found to exert a poisonous effect, while others 
are harmless. The poisons may be present in the decomposing 
cadaver — hence the name ptomain from the Greek for putrefaction — 



SPECIFIC RESPONSES OF THE BODY 27 

and consequently have to be taken into consideration in questions of 
legal medicine. They may be formed also in the living human body, and 
if not made harmless by oxidation, may come to act therein as self- 
poisons or leukomains. These substances possess the characteristics 
of alkaloid bodies and are different from the specific toxins. 

Many ptomains are known and among these are some whose exact 
chemical composition is established, such as cadaverin, cholin and 
muscarin, separated from decomposing dead bodies and cholera cultures. 

The ptomain tyrotoxicon has been obtained from cheese, milk and 
cream. 

Pyocyanin, which produces the color of blue or blue-green pus, is 
a ptomain pigment. Similar bodies of a basic nature may be found 
in the intestinal contents as the products of bacterial decomposition. 

Since the name ptomain was given to the poisonous products of 
bacterial growth before these products were chemically understood, it 
is by many wrongly applied to all poisons found in food. Such 
poisoning is usually due to true toxins or living germs. 

Similar Vegetable and Animal Poisons. — Substances similar to those 
classed as bacterial endotoxins (intracellular toxins) and as soluble 
toxins are formed by many varieties of cells other than bacteria. The 
ricin and abrin poisons obtained from the seeds of the Ricinus communis 
and the Abrus precatoria have a number of properties similar to 
those of the diphtheria and tetanus poisons. When injected into suit- 
able animals antipoisons are produced and accumulate in the serum. 
These neutralize the poisons wherever they come in contact with them. 
They resemble the toxins in a general way in the manner in which 
they react to heat and chemicals. They are precipitated by alcohol. 
Through animal membranes they are less dialyzable than albumoses. 
Substances having these characteristics are called toxalbumins. 

Poisonous snakes secrete poisons which have many of the charac- 
teristics of the bacterial albumoses. The venom contains some 
substances similar to peptone and others similar to globulin. The 
former cause general nervous symptoms and paralysis of the respiratory 
center, while the latter cause intense local reaction with hemorrhages 
around the point of injection. The injection of venom into animals 
is followed by the production of antivenins which neutralize the 
venins. When the serum containing abundant irritable antivenom 
is injected into an infected person it has considerable therapeutic 
value. 

The pyogenic action of their proteins is common to all microbes, 
this depending principally upon their being extraneous albuminous 
substances. Pyogenic effects may be produced in like manner by 
extraneous albumins of non-microbal origin. 

Specific Responses of the Body. — When the nitrate of a seven- 
day-broth culture of the diphtheria bacillus is injected in sublethal 
doses into animals, for instance the horse, the cells react with the 
production of an antibody against the toxin. This substance is 
called "antitoxin." Its production is shown by the fact that increas- 



28 RELATION OF MICROORGANISMS TO DISEASE 

in<; dosos of the toxin can be injected till hundreds or thousands of 
fatal doses can be given without causing death. Likewise, it can be 
shown that mixing the blood or serum of the horse with toxin will 
result in neutralization of the toxin. This neutralization follows a 
multiple scale, thus if one part of serum will neutralize one part of 
toxin, one thousand parts of serum will neutralize one thousand parts 
of toxin. 

In the filtrate of a seven-day-broth culture of the typhoid bacillus 
the antibodies produced are practically all antibacterial. Although 
the filtrate may be toxic, we find that the size of successive doses 
can be increased but not to any extent comparable with that noted 
above. After the horse has received a series of injections the serum 
will neutralize the toxic action of the typhoid bacillus protein to 
some extent but such neutralization will not follow a multiple scale. 
As the amount of "endotoxin" is increased the multiple of serum 
required will have to be much greater. If the amount of "endo- 
toxin" is still further increased neutralization becomes impossible 
however much serum is added. If further tests are carried out it will 
be found that the antibodies produced are dominantly antibacterial 
in character. That is, the antibodies are antiprotein in character, the 
bacillus substance stimulating their production. 

The mechanism underlying recovery, therefore, in all infections is 
essentially antibacterial in character, that is the development of 
specific antibacterial antibodies and their action as well as that of the 
phagocytic cells. Acquired immunity through infection is in most 
instances essentially antibacterial in character. 

Another phenomenon is intimately associated with the process of 
recovery as well as with the development of immunity, viz., hypersen- 
sitiveness or anaphylaxis. This is made use of for diagnostic purposes 
as is the use of tuberculin in tuberculosis and mallein in glanders. 

There are no demonstrable differences in the phagocytic cells them- 
selves before and after the acquisition of active immunity. That is, 
an acquired increased phagocytic power of the cells does not play 
any part in active immunity. There may be present, however, 
an increased number of those antibodies which act as an aid to 
phagocytosis. 

Summary. — Neutral resistance to invasion by bacteria is due to 
some extent to the protective covering of the physiological exterior 
of the body as well as to the protective action of the secretions 
which are discharged on these surfaces. Neutral resistance or 
immunity to infection may exist because of the possession of anti- 
bodies as well as because of the activities of the phagocytic cells. 
A natural immunity may be specific in which case the immunity 
is essentially antibacterial in character. Such an immunity is 
only relative. In the case of diphtheria a natural antitoxic immu- 
nity may exist which is complete. Infection causes a more or less 
marked increase in antibacterial antibodies which are apparently 



SPECIFIC RESPONSES OF THE BODY 29 

essential in the recovery from disease. Phagocytosis likewise is an 
important factor in such recovery. An acquired immunity through 
infection or artificial inoculation by microorganisms which do not 
produce an extracellular toxin, is probably also dependent upon the 
stimulus to the development of specific antibacterial antibodies. In 
both the mechanism of recovery of disease and of acquired immunity, 
sensitization of the cells to bacterial products is an important factor. 
An acquired antitoxic immunity develops after infection in only a 
small proportion of cases. It can be produced in nearly all susceptible 
persons through inoculation. 

Cellular Activity of Antibodies. — It is evident in the light of the 
large amounts of antibodies that might be produced in response to 
the injection of small amounts of toxin, that the antibodies were 
secreted by the body cells and were not due to a conversion of bacterial 
products. 

The antibodies have been found to be a globulin-like substance and 
because the proteins of one species of animal are foreign bodies in 
another it is found that the antibodies produced by the horse are 
retained a much shorter time after introduction in man or other ani- 
mals than others transferred to another horse. Thus an injection of 
tetanus antitoxin gives immunity in the injected horse of some months' 
duration, while in man immunity is only certain for from ten days to 
three weeks. 

Theories Concerning the Production and Action of Antibodies. — It was 
soon evident to early investigators, especially in the light of the large 
amounts of antibodies that might be produced in response to the injec- 
tion of small amounts of toxin, that the antibodies were secreted by the 
body cells and were not due to a conversion of bacterial products. 

On this basis Ehrlich elaborated his well-known " side-chain theory." 
This theory was first advanced in the attempt to explain the nutritive 
process of cells. He conceived the cell as consisting of a complex central 
chemical nucleus of relatively constant structure to which the cell owed 
its peculiar functional character. Attached to this are many "side 
chains" which because of their affinities can take the appropriate food 
molecules from the body fluids. After such combination the food mole- 
cule is assimilated and incorporated in the central nucleus. This con- 
ception places the nutritive activities on a chemical basis. When infec- 
tion occurs the toxins or other products combine with the cell by the 
same mechanism if there is an affinity between any of the side chains 
and the molecules of toxin or other microbal product. These products 
may find suitable side-chain, " receptors or haptines," in many varieties 
of cells or in only the cells of certain tissues or organs. When the 
microbal products combine with the side chains the molecules are 
available not simply as foodstuffs but are actually deleterious and the 
side chain or receptor is destroyed ; or, if sufficient receptors are involved 
the central nucleus is injured and dies. When the nucleus lives the 
receptors are regenerated. In this regeneration, however, the concep- 



30 



RELATION OF MICROORGANISMS TO DISEASE 



tion of overproduction as advanced byWeigert comes into play: that is, 
the injury not only stimulates the regeneration of the destroyed recep- 
tors but an excess of these receptors. The cell possessed of more recep- 



-B 




Fig. 1. — Graphic representation of receptors of the first and third orders and of 
complement as conceived by Ehrlich: A, toxophorous group of toxin; B, haptophorous 
group; C, complement ; D, intermediary or immune body; E, foreign cell receptor; F, 
part of cell. A B unites directly with E; C unites by means of D. 




Fig. 2. — Receptors of the second order. 
Here c represents the haptophore group, 
and d the zymophore group of the receptor, 
/ being the food molecule with which this 
receptor combines. Such receptors are 
possessed by agglutinins and precipitins. 
It is to be noted that the zymophore group 
is an integral part of the receptor. 




- G 



• D 



. F 



Fig. 3. — Graphic representation of 
amboceptors or receptors of the third 
order and of complement, showing on left 
the immune body uniting complement to 
foreign cell and on right the action of anti- 
complement, binding complement and so 
preventing its union with the ambocepter. 
C, complement; D, immune body; E, recep- 
tor; F, foreign cell; G, anticomplement. 



tors than necessary for its nutritive process casts the excess off into the 
body fluids, these cast off receptors now constituting free antibodies. 



SPECIFIC RESPONSES OF THE BODY 31 

It is conceivable that if the stimuli to the cells were continued by the 
repeated partial destruction of receptors, large amounts of anti- 
bodies would be found in this way. The theory explains the general 
specific character of the antibodies as only those cell receptors are over- 
produced which have an affinity for the products of the infecting 
organism. The very bodies that when connected to the cell "sessile" 
made possible the poisoning of the cell, constitute the antibodies when 
free. 

Bordet has shown that toxin unites in different multiples with anti- 
toxin, so that the toxin molecule may have its affinity slightly, partly 
or wholly satisfied by antitoxin. If slightly satisfied, it is still feebly 
toxic; if combined with a larger amount of antitoxin it is not toxic, 
but still may, when absorbed into the system, lead to the production 
of antitoxin. If fully satisfied it has no poisonous properties and no 
ability to stimulate the production of antitoxin. 



CHAPTER II. 

ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 
INDIVIDUALLY CONSIDERED. 

By WILLIAM H. PARK, M.D., 

AND 

CHARLES KRUMWIED, Jr., M.D. 

AGGLUTININS. 

By the phenomenon of agglutination is meant the aggregation into 
clumps of microorganisms uniformly dispersed in a fluid. If the organ- 
isms are motile they become immobile during this process. Many 
substances other than those in serum cause the agglutination of cells. 

This phenomenon (agglutination), while it had been noted by earlier 
observers (Charrin and Roger in 1889), was first extensively studied by 
Gruber and Durham in 1896, who determined that the serum of those 
passing through certain infections contained a specific substance (agglu- 
tinin) which caused the infecting organisms to clump. Several months 
later Widal reported that in typhoid fever the development of agglu- 
tinins could be used for diagnostic purposes. It was thus demonstrated 
by these studies and those of Grunbaum, Bordet and others that 
through agglutinins a new means was available for the identification 
of bacteria and in many cases the nature of the infectious organism 
causing disease. 

Agglutinogen. — The antigenic substance stimulating the production 
of agglutinins is called the agglutinogen. It is formed in the living or 
dead microbal cell and appears to be released in cultures only on the 
dissolution of the organism. Heat and chemicals tend to destroy or 
alter agglutinogenic action. According to the Ehrlich hypothesis we 
may look upon the agglutinogen as a protein molecule having a hapto- 
phore group through which it combines with the cell receptor. (See 
Fig. 2.) Evidence has been advanced that the agglutinogen is 
contained in the ectoplasmic portion of microorganisms. 

Mechanism of the Agglutination Reaction.- — Agglutination is not a 
vital phenomenon. The microorganisms play a purely passive role. 

The observations of Bordet showed very definitely that agglutination 
was a physical phenomenon and that the combination of antigen and 
antibody was one phase, and agglutination another. Thus if a sus- 
pension of bacteria and a sample of serum be dialyzed until all salts are 
removed their mixture will not result in agglutination, unless salt be 
added. Or if the dialyzed mixture be centrifuged to remove the bacteria, 
and the sedimented bacteria suspended in salt solution agglutination 
will promptly occur. If sufficient bacteria have been used the super- 



AGGLUTININS 



33 



natant fluid is free of agglutinins as shown by the absence of agglutina- 
tion when salt and fresh bacteria are added. In other words combina- 
tion occurs in absence of salts by agglutination only in their presence 
or, otherwise stated, agglutination is a clumping of the bacterium- 
antibody complex by salt action. These observations led to a com- 
parison of the agglutination phenomenon to the flocculation of one 
colloid by another and the flocculation of colloids by salts and acids 
(electrolytes) . 

Measurement of Agglutinins or Titration of an Agglutinating Serum. — 
The agglutinating power of a serum is measured by determining the 
highest dilutions in which it still exhibits this quality. The titer of the 
serum as commonly used implies the highest dilutions in which complete 
agglutination still occurs. The results may be stated in another way, 
the titer is the smallest amount of serum which will agglutinate an 
arbitrarily selected standard amount of culture. The titer will vary 
according to the three factors, density of suspension, temperature of 
incubation and time of incubation. The denser the suspension the 
more agglutinins will be required. Agglutination proceeds relatively 
more rapidly as the temperature is raised from 20° to 55° C. The 
reaction may be observed under the microscope, "microscopic 
method/' or by the eye using test-tubes or slide "macroscopic methods" 
(see below, Technic of Agglutination Reactions) . 



\^ ~— — - — °---^\ \ ~s 



Typhoid' bacUlus. 



3 




Paratyphoid bacillus. 
E H 



Colon bacillus. 
Fig. 4. — Specific and common agglutinins producing protoplasm. 

Specific (Major) Group and Normal (Minor) Agglutinins. — Allied 
species of bacteria have protein substances that are more or less similar 
(Fig. 4). If these common substances stimulate the production of 
agglutinins, the relative amount of each agglutinin should be some- 
what proportional to the amount of agglutinogenic protoplasm pos- 
sessed by the infecting or injected microorganism. Thus a serum from 
a typhoid patient may agglutinate B. typhosus in dilutions of 1 to 160, 
B. paratyphosus, 1 to 20, B. coli, not at all. The specific or major 
agglutinins should be present in greatest amount because the greatest 
stimulus is given by the preponderance of the specific typhoid protein, 
the group, common or minor in proportionately less amounts. This 
parallelism is not always followed, thus the serum from a case of para- 
typhoid fever may agglutinate B. typhosus as well as or even better 
than the infecting type. Likewise, the serum of an animal injected 
with B. paratyphosus B. may agglutinate a related but distinct bac- 
terium, B. cholerse suis, as well as the homologous bacterium. Several 
3 



34 



ANTIMICROBAL OR AN TI PROTEIN SUBSTANCES 



factors influence the relative production of major and minor agglutinins, 
especially the duration of the agglutinogens stimulation, that is, the. 
duration of the infection or the number of injections in the case of 
artificial immunization. The following chart serves as an example. 
Evidently the longer the period the greater is the probability of the 
production of considerable group agglutinins (Pig. 5). 

Another factor is the nature of the host. Thus the rabbit, as a 
rule, produces less group agglutinins than does the goat, whereas the 
horse produces very large amounts of common agglutinins. There is 
a relationship between the production of group agglutinins and the 
degree to which agglutinins are normally possessed by the host. Nor- 
mal agglutinins having group activity may be present for several or 
many varieties of bacteria. Thus the serum of man frequently agglu- 
tinates the typhoid or colon bacillus in dilutions of 1 to 1 or even 1 to 5. 



1:5000 
















1:4500 
















1 :4000 
















1:3 500 
















1:3000 














rt. 


1:2 500 












$ 


?• 


12000 












>?/ 




1 :i 500 








.v^ 




4? 




1:1000 










•^ 


tf. 




l: 500 










^9 






l: 00 




=r~i - 






- -* 







Fig. 5. — A young goat was used for the injection of the colon bacillus X. The 
great accumulation of common agglutinins for the paradysentery bacillus in the third 
month of the injections of bacillus X is very striking. 

• Tests made. 



The serum from a normal horse may agglutinate these types in dilutions 
of 1 to 100 or 1 to 1000 or even more. The possession of such agglu- 
tinins we may assume to be due partly to the reaction to the continued 
absorption of intestinal bacteria of the colon group. Such an explana- 
tion, however, does not explain the fact that normal horse serum 
usually agglutinates the glanders bacillus in dilutions of 1 to 500 to 1 to 
1000 or more, depending on the method used. 

Possession of normal agglutinins in the species most commonly 
employed for the production of agglutinating serum is relatively as 
follows: rabbit, slight or absent; goat, moderate; horse, high to very 
high. This parallels, as above noted, the degree of group agglutinin 
production. If the varieties of normal agglutinins are carefully tested 
the paradoxical results obtained with some immune sera become clearer. 
Thus a horse serum may contain before injections a high content of 
agglutinins for two bacteria, 13. dysenterise and B. coli. 

Absorption of Agglutinins. — This method advanced by Castellani. 
allows us to differentiate with accuracy between specific and group 



ABSORPTION OF AGGLUTININS 35 

agglutination. The specific agglutinins and also the common agglu- 
tinins which are stimulated by the infecting or injected bacterium 
should be bound by the homologous organism; in other words, if we 
add to a serum a large amount of its specific organism and then incubate 
we shall find that the clear serum obtained by centrifuge or filtration 
will no longer agglutinate either the specific organism or any of the 
related types previously agglutinated through the action of the group 
agglutinins. If we absorb similarly the serum with a related type we 
find the specific agglutinins will not be appreciably reduced, whereas 
the group agglutinins for the absorbing strain will have partly or 
wholly disappeared. Examples with moderate and extreme group 
agglutination are shown in the following tables : 

ABSORPTION OF AGGLUTINATING SERUM OBTAINED BY INJECTION OF 

B. TYPHOSUS. 





Highest dilution giving 

complete agglutination 

before absorption. 


Absorbed by 
B. typhosus. 


Absorbed by 
B. coli. 


B. typhosus 


. . 1 to 5000 + + 


1 to 50- 


1 to 4000 + + 


B. coli . . . 


. . 1 to 1000 + + 


1 to 50- 


1 to 50- 



ABSORPTION OF AGGLUTINATING SERUM OBTAINED BY INJECTION OF 
B. PARATYPHOSUS B. 





Agglutination Absorbed by 
before absorption. B. paratyphosus "B.' 


Absorbed by 
' B. cholera? suis. 


B. paratyphosus B. 
B. choleras suis . 


. 1 to 10,000 + + 1 to 50- 
. 1 to 10,000 + + 1 to 50- 


1 to 8000 + 
1 to 50 - 



Absorptive results are susceptible to serious misinterpretation if 
character of the serum before immunization, especially the content in 
normal agglutinins be not known. 

Absorption results are of value only when ice possess, or knoiv, the 
specific type which caused the infection or was injected. Thus the fact 
that B. typhosus removes all the agglutinins from a patient's serum 
both for B. typhosus and B. paratyphosus, whereas the latter only 
removes them for itself, is no guarantee that B. typhosus is the infecting 
bacterium. The infection may be due to a third related but unknown 
variety, the absorption results being group agglutinin absorption. 
Likewise, given a serum from which B. typhosus and B. paratyphosus 
will only completely remove the agglutinins for themselves is no certain 
proof of the existence of a mixed infection. The infection again may be 
due to a third unknown bacterium, the absorption resulting only in the 
removal of individual varieties of group agglutinins. 

Dead bacteria agglutinate well, although somewhat more slowly, if 
killing is done by the addition of 0.25 per cent, carbolic acid or pre- 
ferably 0.1 per cent, formalin. If killed by heat the temperature should 
not exceed 55° C. Heating to 60° C. diminishes their agglutinability. 

Dreyer found that if a twenty-four-hour bouillon culture of B. coli 
required 1 part of agglutinin to agglutinate it, then if heated to 60° C. 



36 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

it minimi 2.3 parts; if to 80° C, 18 parts; if to 100° C, 24.6 parts, 
lie found the surprising fact that long heating of the culture restored 
to some extent its ability to be agglutinated by smaller amounts of 
agglutinins. Heated thirteen hours to 100° C. the culture was agglu- 
tinated by four parts. 

The Development of Agglutinins. — Appreciable agglutinins do not 
develop until toward the end of the first week of infection, and the 
agglutinin content tends to rise if infection continues, reaching its acme 
at the height of the disease or somewhat later. Animals show the 
development of agglutinins in about the same length of time after 
immunization is begun. Each successive injection tends to stimulate 
the production of further agglutinins until a considerable concentration 
is present. 

Different varieties of microorganisms vary in their agglutinogenic 
capacity. Thus the typhoid-paratyphoid group have a high agglutino- 
genic value, the streptococcus-pneumococcus group a relatively low 
power. Infection by members of the former causes a relatively high 
agglutinin content, whereas infections by the latter cause the produc- 
tion of only a relatively low agglutinin content. The same result is 
obtained after intensive immunization of animals, an antityphoid 
serum giving agglutination in dilutions of thousands or tens of 
thousands being easily obtained, whereas an antipneumococcus serum 
agglutinating above 500 to 600 is only exceptionally produced. 

The amount of infection or injected antigen bears a relative propor- 
tion to the amount of agglutinins produced. 

Practical Applications of the Agglutination Reaction. — The agglutina- 
tion reaction controlled by agglutination absorption is the method 
employed for the determination of the identity of culturally similar 
microorganisms. By this means we have determined, for instance, that 
all races of B. typhosus are alike; that is, that B. typhosus is a distinct 
type or entity. In this connection it is worthy of note that a group 
of bacteria may differ culturally, for instance, in their fermentative 
reactions and still be found to be identical agglutinatively. The 
agglutinative method likewise allows us to separate culturally similar 
members of a definite bacterial species into subgroups, an example 
being the pneumococcus, of which we have three distinct types, and 
also a large group of agglutinatively dissimilar varieties. 

It is obvious that having knowledge of the kind above outlined we 
can then utilize the agglutination reaction to identify a definite type 
such as B. typhosus or determine into which subgroup a bacterium 
belongs, for example, the pneumococcus. With certain groups we shall 
know that the subgroup cannot be determined with certainty unless 
we employ the absorption method (meningococcus). With other 
species we will be satisfied with morphological or a cultural identifica- 
tion because we do not possess the necessary knowledge for further 
agglutinative identification or because the knowledge we have indicates 
the existence of a multiplicity of races. Finally, we may not be able 
to employ agglutination for identification because the bacterium (at 



AGGLUTININS 37 

least most strains) does not agglutinate well or because of its character 
(clumping and adhesiveness, etc.) a good suspension is difficult or 
impossible to make (B. anthracis). In utilizing the direct method for 
identification the precautions are: (1) The serum employed must be 
of high titer to overcome the tendency to resist agglutination shown by 
freshly isolated strains. The serum from infected human beings is 
usually unsatisfactory for this purpose because the titer is much lower 
than that obtainable by intensive immunization of animals. (2) The 
range of specific and group (including normal) agglutinins must be 
known, that is, determined by tests using homologous and related types. 
(3) The unknown type must agglutinate considerably beyond the 
range of group action before identification is considered sufficient for 
practical purposes. 

The reverse application, viz., the determination of the kind of agglu- 
tinins present in a patient's serum, can be utilized for the diagnosis of 
disease. In this method we utilize a known bacterium to identify the 
agglutinins. It should be clearly understood that this method by itself 
does not possess final or absolute value. Thus we test a person's serum 
and find a considerable content of "typhoid" agglutinins. Unless we 
have isolated an infecting typhoid bacillus we cannot prove that they 
are not group agglutinins, developed because of an infection by B. 
paratyphosus or some other similar but infrequent type. Taking the 
findings, however, in connection with clinical facts and our knowledge 
that the majority of continued fevers of typhoidal character are (in this 
vicinity) due to B. typhosus the presence of agglutinins becomes the 
strongest possible evidence of the existence of an infection due to B. 
typhosus. If we suspect the infection to be due to a paratyphoid type 
we can determine whether B. typhosus or B. paratyphosus "A" or 
"B" is agglutinated in higher dilutions. The presumption is that the 
type agglutinated in highest dilutions is the infecting type. This is 
only a presumption, however, as paradoxical results may occur, as we 
have said, due to a high group agglutinin content or oversensitiveness 
of one culture. 

The direct agglutination reaction for diagnostic purposes has only a 
limited application. It can only be applied in diseases in which agglu- 
tinins are freely produced. Even here its practical value may be 
lessened because other simple methods are applicable earlier in the 
disease. Before it can be applied to a specific disease we must first 
determine the range of agglutinins normally possessed by uninfected 
individuals; knowing this we designate a minimum diagnostic dilution 
for a positive test. Although this method may be of little value in the 
early diagnosis of such acute diseases as cholera, it may be of the 
greatest value in making a post facto diagnosis. The agglutination test 
is chiefly used in typhoid and paratyphoid fevers. The use of the 
typhoid-paratyphoid vaccine creates a difficulty which can be overcome 
in most cases by making several careful tests. If the agglutinins are 
found to have increased it is certain that they are due to the occurring 
infection. 



38 



ANTIM1CR0BAL OR ANTIPROTEIN SUBSTANCES 



Technic*— The agglutination reaction may be observed in the hanging 
drop, using the microscope ("microscopic method"), or observed in the 
test-tube with the eye alone or aided by a low power lens ("macro- 
scopic tube method"), or on a glass slide ("slide agglutination method"), 
a modified macroscopic method. 

Technic of Microscopic Reaction (Widal Reaction). — Preliminary dilu- 
tions of the blood or serum are prepared one-half the strength of the final 
dilutions desired. A loop of each dilution is placed on separate cover- 
slips, as well as a loop of the diluent. Then at the side of each drop is 
placed a loop of the culture. The two drops on each slip are then 
mixed with the platinum wire. This results in a doubling of each of 
the blood dilutions. Hollow r -ground slides, the edges of the concavities 
having been smeared with vaselin, are w r armed and placed over the 
cover-slips so as to seal the drop in the concavity. Warming the 



v\ 






^7 V vV^I 1> 



/ 






/\n 



\ 



:^2 



%f> A- V// \' / >J f^Nr, 






Sv 



Fig. 6. — Microscopic field, showing the 
top of a hanging drop in a normal typhoid 
culture. 




Fig. 7. — Microscopic field, showing the 
top of a drop with the typhoid reaction. 



slides softens the vaselin so that it spreads better. The seal must be 
complete or the drops will dry up. The slide is then turned face up 
and the reaction observed under the No. 6 objective (magnification 
about 500 diameters). The drops must hang freely, that is, they 
should not be too large so that there is contact with the hollow of the 
slide. The drop containing diluent and culture alone is the "control." 
This must be carefully observed to eliminate spontaneous agglutination 
and as an index of the motility when a motile bacterium is employed. 

A broth culture incubated for eighteen hours is usually employed in 
the microscopic reaction. When employed for the diagnosis of disease 
a "standard" "culture" is employed, that is, one of known agglutin- 
ability, otherwise the results will not be comparable. Such a culture 
should be one that, due to cultivation on artificial culture media, has 
reached a constant level of ease of agglutinability. 

The beginner is apt to use too heavy a culture. The broth culture 






AGGLUTINATION REACTIONS 39 

may give more delicate and sharper results when diluted by adding 
sterile broth Fig. 6. 

The slides may be kept at room temperature, 20° C. or at incubator 
35° C. The reaction proceeds more rapidly at the higher temperature. 

If the reaction is observed through the microscope in a hanging 
drop a formation of clumps is seen which, if it takes place rapidly, 
reveals the reaction almost completed at the first glance, that is, most 
of the bacilli are in loose clumps and nearly or altogether motionless 
(Fig. 7). Between the clumps are clear spaces containing few or no, 
isolated bacilli. If the reaction is a little less complete a few bacilli 
may be found moving slowly between the clumps in an aimless way, 
while others attached to the clumps by one end are apparently trying 
to pull away, much as a fly caught in fly-paper struggles for freedom. 
If the agglutinating substances are sufficiently present, but still less 
abundant, the reaction may be watched through the whole course of 
its development. Immediately after mixing the blood and the culture 
together it will be noticed that the bacilli move more slowly than before 
the addition of serum. Some soon cease all progressive movement, and 
it will be seen that they are gathering together in small groups of three 
or more, the individual bacilli being still somewhat separated. Gradu- 
ally they close up the spaces between them and clumps are formed. 
According to the completeness of the reaction, either all of the bacilli 
may finally become clumped and immobilized or only a small portion 
of them, the rest remaining freely motile, and those clumped may 
appear to be struggling for freedom. With blood containing a large 
amount of agglutinating substances all the gradations in the intensity 
of the reaction may be observed from those shown in a marked and 
immediate reaction to those appearing in a late and indefinite one 
by simply varying the proportion of blood added to the culture fluid. 

Pseudoreactions. — If too concentrated a solution of dry blood from a 
healthy person is employed a picture is often obtained which may be 
mistaken for a reaction. Dissolved blood always shows a varying 
amount of detritus, partly in the foim of fibrinous clumps and prolonged 
microscopic examination of the mixture of dissolved blood with a cul- 
ture fluid shows that the bacilli, inhibited by substances in the blood, 
often become more or less entangled in these clumps, and in the course 
of one-half to one hour very few isolated motile bacteria are seen. The 
fibrinous elunips alone, especially if examined with a poor light by a 
beginner, may be easily mistaken for clumps of bacilli. Again, the 
bacilli may become fixed after remaining for one-half to two hours by 
slight drying of the drop or the effect of substances on the cover-glass. 

Technic of the Macroscopic Tube Method. — The suspension employed 
may be a broth culture or a suspension in saline of the growth from an 
agar slant. In the case of bacteria which autolyze easily (meningo- 
cocci) the suspensions should be heated to 56° C. to destroy the autolytic 
ferment. Such suspensions may be preserved for future use by adding 
a preservative, such as 0.25 per cent, carbolic acid. The suspension 



40 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

should not be too dense. A very slight clouding gives the sharpest 
results. Broth cultures to which 0.1 per cent, of formalin has been 
added make very satisfactory antigens. Prepare the initial serum 
dilutions 10 times more concentrated than will be the desired end 
dilutions. Place 0.1 c.c. of each dilution in a small chemically clean 
test-tube and 0.1 c.c. of saline in another for a control. To each of the 
tubes add 0.9 c.c. of the bacterial suspension, shake the tubes and 
incubate in the water-bath or incubator at 37° to 55° C. 

If agglutination takes place it is shown first by a change in the appear- 
ance of the suspension. Instead of the uniform opacity there develops 
a ground-glass appearance. If one uses a lens one can see very fine 
clumps. As the reaction proceeds the clumps become more easily 
visible. If after incubation for two or three hours the tubes are allowed 
to stand, preferably in the ice-chest overnight the clumps fall to the 
bottom of the tube. If the reaction is complete the supernatant fluid 
will be clear. In settling, the agglutinated bacteria form a broad 
film over the bottom of the test-tube, whereas the sedimentation of 
non-agglutinated bacteria results in a compact button-like sediment. 

The control tube should always be carefully inspected to exclude 
spontaneous agglutination. 

Comparison of Tube and Microscopic Slide Methods. — The reaction 
is the same in both and one is as reliable as the other. The ice-box 
readings (macroscopic) are apt to be higher than those obtained by 
microscopic examination. For diagnostic examinations in which haste 
is necessary and small amounts of serum are available, as in typhoid 
fever, the microscopic method is preferred. When a delay of twenty- 
four hours is no handicap and the serum is abundant as in tests for 
glanders in horses the macroscopic tube-test is generally used. Dead 
cultures are more frequently used in the macroscopic method because 
the motility here is of no importance. 

Dreyer Method of Macroscopic Agglutination. — The basis of this 
method is the employment of a standardized antigen. This makes 
more uniform and comparable results possible. The method was 
suggested primarily as a means by which the rise or fall of agglutinins 
could be accurately determined. Thus, Dreyer believes typhoid or 
paratyphoid fever can be differentially diagnosed in the vaccinated 
because the rise or fall of the infection agglutinins is marked within 
short periods, whereas the agglutinins due to vaccination will be rela- 
tively stable during a similar period. To be able to determine a rise 
or fall with accuracy it is obvious that a standardized antigen must be 
employed. 

The antigen is prepared by subculturing daily in broth for about ten 
days. Then flasks of broth are inoculated and incubated for twenty- 
four hours. Add 0.1 per cent, of formalin (40 per cent, formaldehyde 
solution), place on ice for several days, shaking repeatedly. The cul- 
ture is then standardized for opacity and agglutinability. Dilutions 
of the culture are compared with dilutions of a standardized culture 



AGGLUTINATION REACTIONS 41 

and the degree of greater density of the new culture determined by 
taking the mean of at least six successive selections of tubes of similar 
density. The culture is diluted accordingly with physiological salt 
solution containing 0.1 per cent, formalin and tested for agglutinability. 
This is done by comparing the results of agglutination with that 
obtained with a previously standardized culture. The new suspension 
is then given a factor of agglutinability based on comparison of the 
highest dilutions showing agglutination to the naked eye. The dilution 
of the standardized culture is to that of the new culture as the factor 
of the former is to that of the latter. The original standard had a 
factor of 1, and to make results with subsequent antigens comparable 
they must be corrected according to this factor. 

If one possesses no standardized culture the optimum opacity may 
be determined by setting up agglutinations with various dilutions of 
the antigen and determining which gives the sharpest readings. One 
can always standardize back to this original antigen and can at any 
time transfer the results in terms of another standard culture. 

Dreyer recommends incubation at 55° C. for two hours. For further 
details, including the methods Dreyer uses in expressing the results, 
reference is made to the article by Davison. 1 We have found the use 
of formalinized broth cultures of standardized opacity of the greatest 
value in carrying out extensive experimental work with members of the 
typhoid, paratyphoid and dysentery group. The use of agglutination 
antigens thus standardized is preferable in determining the curve of 
agglutinin response to vaccines in man or in animals, especially when 
the agglutinin response is used as a presumptive indication of the anti- 
genic value of the vaccine. Exceedingly sharp readings are possible 
if the tubes are placed on ice overnight. The sharp results are due 
apparently to the sensitiveness of the antigen as well as its dilution, 
which results in fewer grades of intermediate reactions. 

The Macroscopic Slide Method. — This method allows a rapid diag- 
nosis of colonies from plates inoculated with suspected material, such 
as feces, throat cultures, etc., and can be employed in examinations for 
cholera, typhoid, paratyphoid and dysentery bacilli as well as for 
meningococci. A highly potent serum, whose specific and group agglu- 
tinating strength is known, should only be used, or false positive results 
will be obtained; hence the method is not of much worth in clinical 
diagnosis of blood. 

The method is as follows: A loopful of saline solution (as control) 
and one of the highly potent specific seruni in low dilution are placed 
on one slide and a sufficient amount of the suspected colony to give a 
slight turbidity is added to each. Flocculation begins in the serum 
almost at once if the organism tested is specific. A negative reaction 
is not exclusive, as relatively inagglutinable strains may be encountered, 
although with highly potent serum there is nearly always some evidence 

• ! Jour. Am. Med. Assn., 1916, lxvi, 1297; also Fennel; Jour. Am. Med. Assn., 1918, 
lsx, 590. 



42 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

of a reaction. Colonies apparently typical but not distinctly agglutin- 
able should be fished for further identification. Colonies giving a posi- 
tive reaction should also be fished for verification, unless experience has 
shown that the serum used does not give false positive results with 
allied types. 

PRECIPITINS. 

Precipitins are antibodies which, when added to a clear protein solu- 
tion, cause a precipitation. In 1897 Kraus noted that if the serum of 
an animal immunized against B. typhosus is added to bacteria-free 
filtrates of broth cultures the mixture first became turbid, which change 
was followed by precipitation. Similar results were obtained with 
other antisera and their homologous bacteria. 

Nature of Precipitins — The properties of precipitins are very similar 
to those of agglutinins. They are fairly resistant, but are gradually 
destroyed by heating to 60° to 70° C. Ehrlich and Bordet consider 
the precipitin antibody as having the same structure as the agglutinins. 
Ehrlich classes it as an antibody of the second order. The loss of 
activity of precipitins according to this conception would be due to 
the deterioration of the more labile zymophore group, resulting in the 
formation of "precipitinoids." Precipitins are specific within certain 
limits. 

Mechanism of the Precipitin Reaction. — If we look upon the precipitin 
antigen, that is, the clear solution of bacterial proteins as simply a sus- 
pension of invisible protein molecules as contrasted with microscopically 
visible bacteria in an agglutination antigen, the mechanism must be 
similar to that of the agglutination reaction. The known facts and 
theories of the mechanism of one reaction apply in general to the other. 

Development of Precipitins. — Precipitins are not commonly demon- 
strable in the serum of infected individuals. This antibody is usually 
present in appreciable amounts only after prolonged and intensive 
immunization. The precipitinogen, that is, the stimulant to its pro- 
duction, may be live or dead bacteria or solutions of their proteins 
obtained by extraction or autolysis. 

Practical Applications of Precipitin Reaction. — The precipitin reaction 
has only a limited application in the identification of bacteria in culture 
and body fluids and discharges. It is less easily applied than the agglu- 
tination reaction, because of the necessity of preparing a clear bacterial 
extract. Another disadvantage is that the range of precipitin action of 
an antiserum is relatively low. At the present the reaction is limited 
in practical work largely to the differentiation of the types of 
pneumococcus. An important application is the determination 
of the presence and variety of bacterial substance in excretions, 
exudates or lesions. Thus, in lobar pneumonia considerable soluble 
products of the pneumococcus are found in the lung, in the sputum, 
in the blood and thence in the urine. Advantage is taken of this fact 
by using the precipitin reaction to determine the type of infecting 






PRECIPITINS 43 

pneumococcus. Likewise, if the sputum is injected intraperitoneal^' 
into the mouse the precipitin reaction may be similarly applied to the 
peritoneal exudate. In the case of anthrax infections in animals, 
extracts of the lesions frequently give a precipitin reaction with immune 
anthrax serum, thus permitting a diagnosis. 

The precipitin reaction with the serum of the infected host, because 
of the absence of appreciable amounts of precipitin, has been applied 
practically very little in the diagnosis of disease. The serum of horses 
infected with glanders usually gives a precipitin reaction, and the 
method has been used for diagnosis. The results are less reliable than 
those obtained with the agglutination or other serological reactions. 

The Nature of the Precipitin Antigen. — As is evidenced by the methods 
of preparation given above, the antigen, using this term in the narrow 
sense of the reacting substance, resists boiling even in the presence of 
acid and alkalies. In fact, its resistance is so extraordinary that 
it is not destroyed by boiling in strong alkaline hypochlorite solution 
even for one-half hour or longer. Pick also found that the precipitin 
antigen was not destroyed by decomposition or digestion by pepsin or 
trypsin. Certain data indicate the existence also of a thermolabile 
and alcohol-soluble precipitable fraction in bacterial extracts. 

Although the substance is present in greatest amounts in broth cul- 
tures after incubation of twenty-four to forty-eight hours or longer it 
is demonstrable in young cultures of the pneumococcus, for instance, 
after four to six hours. 

Other Antibodies in the Precipitate. — Agglutinins, bacteriolysins, com- 
plement-fixing substances and protective antibodies are carried down 
with the precipitate. These can be dissociated to some extent from 
the precipitate by extraction with weak alkaline solutions. 

Precipitins for Other than Microbal Proteins. — Tchistovitch and 
Bordet showed that the injection of alien serum would result in the pro- 
duction of precipitins for the injected serum. Similarly, precipitins 
can be prepared for vegetable proteins. Further observations revealed 
that this reaction had species specificity, that is, the reaction occurred 
quantitatively highest with sera from individuals of the same species 
as used for injection. The degree of group reaction with sera of other 
species depends on the closeness of biological relationship of the species. 
The antiserum precipitin will react with the other albuminous secretions 
of the same species. By washing organs free of blood a certain degree 
of organ specificity seems demonstrable. One peculiar fact is worthy 
of note, however, the crystalline lens from fishes to man has the same 
protein content as determined by the precipitin reaction. 

Practical Applications. — Because of the marked species specificity the 
precipitin reaction may be employed to identify the source of blood 
stains for medicolegal purposes. It is also applied in the determina- 
tion of the sophistication of foods. 

Given a blood stain, presumably human, the first step is to prove 
that it is blood. If the blood cells have disintegrated, this is done by 



44 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

chemical means, preferably by the demonstration of hemin crystals. 
The extract of the stain in salt solution is used as the antigen in 
the test. In the ease of meats a salt solution extract of the meat, or, 
for instance, sausage, is made and used as an antigen with antibeef, 
antihorse, antidog, etc., sera. That giving reaction in dilutions com- 
mensurate with controls of known meat gives us our result. The anti- 
sera are obtained by several large injections of the species serum into 
rabbits. The technic of the reaction is based on the fact that even 
very dilute amounts of antigen are demonstrable. The antigen is 
diluted, therefore, not the serum. With very potent antisera even 
dilutions of 1 to 25,000 or more of the antigen will give a reaction. In 
the cases mentioned above an estimated initial dilution of 1 to 1000 is 
prepared, from which other dilutions can then be made. The antigen 
is then floated over the serum and incubation carried out at 37° C. 
The appearance of a ring at the point of contact is a positive reaction. 
The reagents must be clear and many controls with other antisera and 
known antigens are necessary to exclude error. In a few attempts we 
have been only moderately successful in differentiating between cold 
storage horse meat and beef. 



BACTERIOLYTIC ANTIBODIES. 

In 1888 Nuttal demonstrated that normal blood had a bactericidal 
or bacterium-killing property without regard to the presence of phago- 
cytic cells. He showed that serous exudates contained similar sub- 
stances and found that the bactericidal action was weaker after standing 
and was quickly destroyed by heating to 60° C. Buchner found the 
same property was possessed by serum obtained after the clotting of 
blood and called the active substance "alexin." Pfeiffer, in 1894, 
showed that if guinea-pigs were first immunized against the cholera 
vibrio and then injected intraperitoneally with living cholera vibrios 
there was a rapid swelling, granulation and dissolution of the bacteria. 
This process could be followed by removing portions of the peritoneal 
exudate with capillary tubes and examining it in stained smears. A 
normal guinea-pig would not show this phenomenon or at most slightly, 
but the phenomenon could be induced even with normal pigs if "im- 
mune" serum were introduced with the vibrios. The same result 
occurred if the serum was first heated to 60° C. This is known as the 
"Pfeiffer phenomenon." The active substance, therefore, was an 
acquired antibody, and, as he showed, was specific, acting only on the 
cholera vibrio. The hypothetical substance causing this action, 
Ffeiffer called "bacteriolysin," or specific bactericidal substance. 

Bordet then showed that the phenomenon was due to the interaction 
of two substances, one the specific substance, increased during immuni- 
zation, which was thermostabile (50° to 60° C). He also showed that 
fresh immune serum is actively bactericidal, but if this power were lost 
by standing or by heating it could be fully restored by the addition of 



BACTERIOLYTIC ANTIBODIES 45 

fresh guinea-pig serum which possessed little bactericidal action by 
itself. 

The Immune Body or Amboceptor. — The terms bactericidal or bac- 
teriolytic are used to denote whether the bacterium is only killed or 
killed and disintegrated. There is no evidence that we are dealing with 
two distinct antibodies. The term amboceptor was adopted by Ehrlich 
because he believed that the antibody was a cell receptor having two 
haptophore groups, one with an affinity for the bacterium the other for 
combination with the third substance normally present in serum, which 
he called complement. 

He termed the amboceptor an antibody of the third order. They 
resist heating to 60° C, but are gradually destroyed by heating to 70° 
to 80° C. The amboceptor combines with the cell in the absence of 
complement. As with other antibodies, those produced during immuni- 
zation have highly specific as well as some group action. They are also 
normally present to a varying degree, as noted above, in results 
obtained by Nuttal and others. 

The Complement. — Complement is present in normal and in immune 
serum. Its quantity is not increased during immunization. It is the 
active substance in bacteriolysis. Its structure, according to Ehrlich, 
is very similar to that of a toxin possessing a haptophore group for com- 
bination with the receptor and an active or cytophile portion to which 
it owes its action. The latter portion is unstable, deteriorating when 
serum is left at room temperature for forty-eight hours or longer, and is 
destroyed by heating to 55° C. for one-half hour, and is very sensitive 
to acids and alkalis. The residual haptophore group Ehrlich terms a 
complementoid, and believes that it will combine with the receptor, 
thus preventing the action of active complement. Such evidence as is 
available indicates that the leukocytes are a source, if not the only 
source of complement. How many varieties of complement exist is an 
open question. Bordet believes there is only one variety, whereas 
Ehrlich and others have advanced what they consider evidence to prove 
the existence of many varieties. Complement in its action resembles 
ferments very closely. (See below.) 

Mechanism of Amboceptor-Complement Action. — According to Ehr- 
lich's hypothesis the amboceptor acts as a bridge for the action of 
complement. Bordet, however, believes that amboceptor combines 
with the bacterial cell, sensitizing it to the action of the complement. 
In favor of such a conception is the fact that complement shows little 
if any affinity for the immune body in the absence of the homologous 
bacterium. If the amboceptor were simply a double haptophore bridge 
the complement should combine with the amboceptor. Here, again, 
we find differences in theoretical considerations based on hypotheses of 
quantitative chemical combination or on the more physical theories of 
colloidal adsorption. The combination of the antigen with amboceptor 
and complement is approximately quantitative as with other antibody 
combinations. The most important variation in quantitative relation- 
ship is seen in the fact that if the amount of amboceptor is increased 



46 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

less complement is needed, whereas if the amount of complement is 
increased less amboceptor is needed. Even though the mixtures of 
bacteria, its homologous amboceptor, be incubated for prolonged 
periods there is no evidence of proteolytic cleavage, yet the bacteria 
may be dissolved. The action of the complement on the amboceptor- 
cell complex would seem to be upon the cell envelope and stromata, 
making it permeable and liberating the protein content. Amboceptor 
and complement have different avidities in relation to temperature; 
thus amboceptor will combine with the bacterial cell even at a tem- 
perature just above the freezing-point, whereas complement will only 
combine with the cell-amboceptor complex at higher temperatures, its 
optimum being at 37° C, at which temperature it also displays its high- 
est activity. Amboceptor and complement are fixed by the substances 
in extracts of bacteria, even in the absence of demonstrable precipi- 
tation. (See Precipitins.) 

Determination of Bactericidal or Bacteriolytic Action. — The activity 
of a serum may be determined by in vivo and in vitro methods. The 
PfeifYer phenomenon in guinea-pigs is utilized for the former. The test 
is carried out by injecting a series of guinea-pigs intraperitoneally with 
a constant amount of culture and decreasing amounts of the serum. 
The reaction is observed by removing portions of the peritoneal 
exudate to determine the degree of action. The smallest amount of 
serum yielding a positive reaction gives us the titer of the serum. 

The test-tube method is usually carried out according to the technic 
of Stern and Korte. To a series of test-tubes add decreasing amounts 
of the inactivated 'heated to 55° C. half hour) serum. To each tube 
then add 0.1 c.c. of fresh guinea-pig serum to supply a constant amount 
of complement. Add saline to bring the contents of each tube to con- 
stant amount, 0.5 or 1 c.c. To each tube add a small amount of dilute 
suspension or broth culture of the homologous organism. Incubate 
for three hours at 37° C, and then make poured agar plates of the con- 
tents of each tube and incubate and determine the relative number of 
colonies developing. Adequate controls must be made, a salt solution 
control before and after incubation, an amboceptor control of the lowest 
dilution without complement and of complement alone. The guinea-pig 
serum may be bactericidal itself. The sterility of each of the reagents 
must also be controlled. 

It is obvious that with this method, even though we did not inacti- 
vate the serum we are titrating the amboceptor content as we are 
adding complement to activate the amboceptor in the high dilutions. 
If we wished to determine the actual bactericidal value of native serum 
because of its content of immune body and natural complement we 
should carry out the test in a similar manner employing a constant 
amount of fresh active serum but decreasing the dose of culture. The 
number of organisms in the decreasing dose may be estimated by 
control plating. The largest number of organisms that is killed by this 
constant dose of serum is the measure of the serum. 

The methods are relatively difficult to carry out and unsatisfactory 



BACTERIOLYTIC ANTIBODIES 



47 



results are common with the plate methods because the culture or the 
complement employed are not satisfactory. Reduplication or com- 
parable results are difficult to obtain on successive tests for the same 
reasons. The tests are not applied practically today for purposes of 
identification of bacteria or as a diagnostic procedure. The Pfeiffer 
reaction has lost its importance as a means of identification because 
the simpler agglutination reaction gives us the same information. 

The methods are used primarily for experimental purposes to deter- 
mine the response to injection of vaccines or to compare the bacteri- 
cidal action of serums with the degree of action of other antibodies. 

Relation between Agglutinating and Bactericidal Power. — In spite of 
proof to the contrary, the belief persists that there is regularly a paral- 
lelism between the agglutinating and the bactericidal strength of a 
serum. In Fig. 8 are recorded a number of comparative tests during a 
period of sixteen months. The experiment shows no definite relation 






l:l 200 


Fatal 
















|:l 100 


doses 






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1:1000 


protected 






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I: 900 


Iccserem 






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1: 800 


4.0 




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I: 700 


3.5 




1 




\ 




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I: 600 


3.0 




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1: 500 


2.5 




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I: 400 


2.0 




r 






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1: 300 


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\ / 




\ 


1: 200 


1.0 


/? 








\/ 




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i: ioo 




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i 






l: 00 



















Fig. 8. — Relation of agglutinative to bactericidal power, 
over a period of sixteen months. 

Agglutination index. 

Bactericidal index. 

• Test dates. 



Horse injected 



between content of agglutinins and immune bodies. We have found in 
horses subjected to injections of a fixed type of pneumococcus that the 
agglutinating strength increases more rapidly than the bactericidal 
strength and that it decreases while the latter is still increasing. 

Bordet-Gengou Phenomenon or Complement-fixation Reaction. — If we 
take an antigen, bacterial or non-bacterial, and add to it a small amount 
of inactivated homologous immune serum and complement (fresh 
guinea-pig serum) and incubate the mixture, there will result a com- 
bination of the three elements. If we have not added too much com- 
plement none should be left free. We can determine this to be so by 
adding red cells which have been sensitized by incubation with their 
homologous antiserum. There being no complement free, no hemolysis 
results. If we repeat the experiment and use a heterologous antigen 
or a heterologous antiserum, complement should not be combined. 
This will be shown when we add our "complement indicator," red cell 



ANTIMICItOIlAL OR ANTIPROTEIN SUBSTANCES 



sensitized with their homologous antigen, hemolysis quickly develops 
after appropriate incubation. These facts are diagrammatically 
represented as follows: 



B. typhosus 

+ 

antityphoid 

immune body. 

+ 
Complement. 




Complement 

bound in A, 

not free to act 

on#. 


B 


Red cell 
+ 




antired cell 
immune body. 










(No hemolysis.) 


B. typhosus 

+ 

anticoli 

immune body. 

+ 
Complement. 




Complement 
not bound in A , 
and free to act 

on sensitized 
red cells. 


B 


Red cell 

+ 

antired cell 

immune body. 












(Hemolysis.) 



As we have outlined the reaction it would appear that a positive 
(no hemolysis) result is wholly due to the fixation of complement by 
bactericidal antibodies. This is not the case. Other factors enter. 
We have already referred to the absorption of other antibodies by the 
precipitin-antigen complex. As Gay has shown, this complex will fix 
complement as well. Neisser and Sachs found that very minute 
amounts of human blood mixed with its antiserum would fix comple- 
ment and suggested this method for forensic blood tests. Although the 
injection of blood serum may give rise to amboceptor as well as pre- 
cipitins, most investigators believe the complement is bound by the 
precipitin-antigen complex. The complement may be bound even 
when no demonstrable precipitation occurs. For instance, in the 
presence of an excess of antigen the precipitate may not separate. The 
precipitin-antigen complex held in "solution" by the excess of antigen 
fixes complement. It is evident, therefore, that complement-fixation 
is a much more delicate antigen indicator, that is, the precipitin 
reaction. 

Application of the Bordet-Gengou Phenomenon. — Three applications 
of this reaction should be apparent and theoretically possible: (1) 
The use of known antibodies to identify or classify unknown micro- 
organisms; this application has been used to a considerable extent, 
but has many drawbacks as compared with the simpler agglutination 
reaction. When satisfactory agglutination antigens are not possible 
the reaction has considerable value. Closely allied types tend to give 
greater group reactions than are encountered with the agglutination 
reaction. These may be eliminated to some extent by careful titration 
of the reagents. (2) The second application is the demonstration of 
the presence and the identification of the antibodies in the patient's 
serum. This application is, therefore, a diagnostic procedure. This 
procedure is also employed in strengthening the evidence that a micro- 
organism isolated from a disease is the causative agent. Naturally the 






OPSONINS AND PHAGOCYTOSIS 49 

presence of antibodies does not prove that it is the primary etiological 
agent of the disease or infection, as the antibodies might develop if 
the organism were a secondary infecting agent. (3) The third appli- 
cation is the use of the reaction to quantitatively determine the con- 
tent of complement-fixing antibodies in antibacterial serums to be used 
for therapeutic purposes. 

OPSONINS AND PHAGOCYTOSIS. 

Although it has been suggested by earlier observers that ingestion 
of bacteria by the body cells was a means by which the body destroyed 
bacteria, MetchnikofT was the first to experimentally prove this fact. 
This ingestion is followed by a digestion and is analogous to the feeding, 
processes of unicellular organisms. MetchnikofT noticed that phago- 
cytosis was more active in the presence of immune serum than with 
normal serum, but thought that this was due to the presence of leuko- 
cyte-stimulating substances in the serum. Denys and Leclef suggested 
that the action of immune serum might be upon the bacterium reducing 
their resistance of phagocytosis. By utilizing the technic of Leishman, 
Wright and Douglas definitely proved the existence of a substance in 
serum which, acting upon the bacterium, prepared it for phagocytosis. 
This substance Wright gave the name "opsonin." 




Fig. 9. — Streptococcus engulfed by leukocytes from abscess. Gentian-violet stain. 
X 1000. (Frankel and Pfeiffer.) 

The Phagocytic Cells. — MetchnikofT differentiated two varieties: the 
"motile or wandering" and the fixed phagocytes; the former, the 
leukocytes, the latter the endothelial cells, as well as certain fixed con- 
nective-tissue cells and cells of the lymphoid tissues (lymph-nodes and 
spleen) and of the neuroglia. The most active fixed .phagocytes are the 
endothelial cells of the bloodvessels and serous cavities and lymph 
sinuses. The polymorphonuclear leukocytes he designated as "micro- 
phages," the large mononuclear leukocytes and the fixed phagocytes 
as "macrophages." The participation of these cells is seen in the 
process of inflammation. If an infection occurs, due to the strepto- 
coccus, there is an inflammatory response which is dominated by the 
4 



50 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

collection of polynuclear leukocytes which are attracted ("positive 
chemotaxis") and pass through the wall of the capillaries to the 

tissues. 

At the same time there is an accumulation of serous exudate. The 
polynuclear leukocytes as well as the local phagocytic cells attempt to 
dispose of the bacteria Fig. 9. If the infection progresses, the accum- 
ulation of cells continues and the leukocytes and tissue cells which are 
killed form the resulting "pus." This consists mostly of the accum- 
ulated leukocytes and serous elements. 

If the infection had been due to tubercle bacilli a different type of 
inflammation would occur. The bacilli will be rapidly surrounded by 
large mononuclear cells, apparently endothelial in origin, and about 
the latter will develop an exudation of cells of the lymphocyte type. 
The polynuclear variety is not attracted ("negative chemotaxis ,, ). 
Phagocytosis by the endothelioid cells and the giant cells formed from 
these is noticed. If the infection progresses, necrosis develops in the 
center of the cell mass, resulting in caseation. The polynuclear leuko- 
cytes, however, play a role in the preliminary attempt to dispose of the 
bacilli, as is seen in the phagocytosis when tubercle bacilli are intro- 
duced into a serous cavity. 

In general infections the blood picture, total leukocyte and differ- 
ential count, gives evidence of the positive or negative chemotactic 
character of the infecting organism. If an infection is due to an exces- 
sively virulent organism or if infection be extensive and severe a nega- 
tive chemotaxis results even though the infecting agent is ordinarily 
of the positive variety. 

Opsonins. — Opsonins are present in normal serum and in greater 
amounts in the serum of immune animals. Evidence has been advanced 
that the "normal" and the "immune" opsonins are not similar sub- 
stances. 

Thus the former are nearly destroyed by heating to 60° C. for fifteen 
minutes, whereas the latter seem more heat-resistant, not being mark- 
edly affected by heating to 62° to 03° for forty-five minutes. The 
question arises: What relationship, if any, have these substances to 
those already studied? Careful experiment, indicates that the opsonic 
action of normal serum is due to distinct antibodies. The action of 
normal opsonins is apparently due to a thermostabile (55° C.) sub- 
stance present only in small amounts the activity of which is very much 
enhanced by other thermolabile (55° C.) substances, non-specific in 
character present in the serum. The latter substance is apparently 
the complement. The thermostabile substance is relatively specific in 
the sense that the absorption of normal serum by a specific organism 
will only remove those for itself or related organism, but not necessarily 
all the opsonic substances. 

The immune opsonins or bacteriotropins (Xewfeld) would resemble 
antibodies of the second order (Ehrlich) if the evidence advanced as to 
their heat resistance and inability to be reactivated by normal serum 
was conclusive. Dean, Hektoen and others, although admitting the 



OPSONINS AND PHAGOCYTOSIS 51 

thermostabile character of the immune opsonin, have shown that the 
action is enhanced by the addition of fresh normal serum, inactive in 
itself. It would seem, therefore, that there is no fundamental differ- 
ence between the normal and immune opsonins or bacteriotropins. 
The apparent greater resistance of the latter may be partly because of 
their presence in greater concentration. In both instances the opsonic 
action is not completely lost on heating, thus apparently differing from 
the complete inactivation of bactericidal action brought about by the 
same means. This residuum may remain only apparently active, not 
being active in itself, but because the leukocytes used in the test supply 
traces of complement which reactivates the opsonic antibody. This 
hypothesis, however, rests on the still doubtful contention that the 
leukocytes are a source of complement. If this hypothesis were true 
it would explain the apparently greater heat resistance of immune 
opsonins, which, being in greater concentration, would require less 
complement to activate them. As we have pointed out, the greater the 
concentration of amboceptor the less complement is necessary. The 
fact that the opsonin value and the bactericidal action of a serum do 
not necessarily parallel each other quantitatively, indicates that the 
opsonic action is due to a distinct antibody and not due to the action 
of bactericidal amboceptor either alone or with complement. A final 
opinion, however, will be possible only when the doubtful points of 
opsonic action are settled. 

Immune opsonins or bacteriotropins like other antibodies are specific 
for the stimulating microorganism. Some group action, however, may 
be evident, with closely related types. As with other antibodies, micro- 
organisms exhibit a variable degree of resistance to the action of opso- 
nins. This again is relatively proportionate to their virulence and 
source, and can be artificially modified. The resistance to phagocy- 
tosis may not be wholly due to resistance to the combination of opsinins. 
The bacterium may secrete substances which repel (see aggressins) or 
actually injure the leukocytes (leucocidins) . As has been previously 
noted, capsule production is apparently a protection against antibody 
action. Pathogenic bacteria which have been cultivated on artificial 
media for some time may be spontaneously phagocyted, that is, 
phagocyted in the absence of serum. 

Variations in Activity of Phagocytic Cells. — According to the fact 
given above, one would conclude that the increased phagocytic capacity 
of the cells of the immune host were wholly due to the increased 
opsonins. It has been shown that in lobar pneumonia the leukocytes 
may show an increased phagocytic power without regard to serum 
action. This may be due to other factors, as for instance, the age of the 
cell rather than to an acquired cell characteristic. Park and Biggs 
have shown that differences exist between the cells of apparently 
healthy individuals. Probably an equal degree of difference occurs 
with cells of the same individual at different times. 

Mechanism of Phagocytosis.— The phenomenon of chemotaxis and 
of phagocytosis can be simulated with inanimate physical agents. A 



Y> 



ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 



study of these agents indicates that chemotactic action is due to sub- 
stances which lower the surface tension of the cell. This causes attrac- 
tion and results in phagocytosis, thus if the leukocyte meets a 
substance which reduces its surface tension it flows about or engulfs 
the substance. After ingestion, microorganisms are subjected to the 
action of the endolysins or ferments by winch they are destroyed and 
digested. 

Endolysins and Endo-enzymes. — Leukocytes, as shown by Schatten- 
froh, contain bactericidal substances. These can be extracted. They 
differ from similar serum antibodies in that they are more thermo- 
stabile, a temperature of 75° to 80° C. being necessary to destroy 
them. These substances have been termed " endolysins." Zinnser 
showed that one could extract no greater amount of these substances 
from the cells of immune than from normal individuals. Endolysins 
are not specific. Little if any of this substance is contained in the 
lymphocytes and macrophages. A number of enzymes have also been 
obtained from phagocytic cells, those of the leukocytes being called 
leukoprotease. Opie obtained two proteolytic ferments in the cells of 
exudates, one from the polynuclear cells, active in weak alkaline solu- 
tions, the other from exudates containing large numbers of mononuclear 
cells, active in weak acid solutions. The leukocytes possess no lipase 
which, how T ever, is present in the macrophages. The leukocyte, there- 
fore, cannot digest acid-fast bacilli such as the tubercle bacillus but 
carries them to the lymph nodes for digestion by the macrophage. In 
this w T ay tubercle bacilli or other microorganisms, which resist the 
power of the leukocytic endolysins and endoferments may be dis- 
seminated by w T hat is essentially a protective mechanism. Because of 
the presence of the above substances extracts of leukocytes may on 
injection have protective or therapeutic value. 

Technic of Demonstration and Measurement of Opsonic Action. — 
Viable leukocytes may be obtained from sterile exudates or from the 
blood. In the former a 5 per cent, aleuronat suspension in a 3 per cent, 
starch solution in broth or a 25 per cent, solution of peptone is injected 
intraperitoneally into a guinea-pig or intrapleurally into a rabbit. 
After sixteen to twenty-four hours the animal is killed and the exudate 
is collected and added to about 20 c.c. of a 1 per cent, sodium citrate in 
an 0.8 per cent, salt solution. This is centrifuged, the leukocytes are 
again suspended in saline and are again sedimented, three or four times 
successively to w T ash away traces of serum. The leukocytes are then 
suspended in saline. Leukocytes are obtained from the blood by adding 
1 part of blood to 15 to 20 parts of citrate salt solution, which prevents 
clotting. Small amounts, 1 c.c, may be obtained by deep puncture of 
the finger or the blood may be obtained from the vein by syringe. The 
blood of experimental animals may be used. The diluted blood is 
centrifuged at low speed. The red cells, having the greater specific 
gravity, are sedimented first, the leukocytes last, collecting as a creamy 
layer over the red cells. 

The supernatant fluid is removed without disturbing this layer, and 



OPSONINS AND PHAGOCYTOSIS 53 

leukocytes are collected with a capillary tube. They will be mixed with 
red cells. The leukocytes are now placed in saline in another centrifuge 




Fig. 10.— Opsonic outfit. (Wright.) 



tube, centrifuged and the cells washed free of serum as described above, 
and finally suspended in saline. The solutions employed should be 



54 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

warmed to 37° C. as cold will affect the activity of the cells. Centri- 
fuging at too high speed is to be avoided as this may clump the leuko- 
cytes. For careful work and especially if the activity of different cells 
is to be compared the cells in the suspensions should be counted and 
standardized to a definite content of polynuclear leukocytes. 

The bacterial suspension may be either a saline suspension of the 
growth on agar or a broth culture. The culture selected must not give 
undue spontaneous phagocytosis nor should it be unduly resistant to 
opsonic action. The suspension must be of a satisfactory density. 

The serum is collected from man by puncture, allowing the blood to 
flow into a Wright capsule (Fig. 10, c). The blood of experimental 
animals is collected from the vein and placed in a test-tube to clot. 
If necessary the clot is loosened from the glass so that it will contract 
and the serum separate. 

The Method of Wright-Opsonic Index. — This method gives a com- 
parison between the opsonic action of a serum with that from a normal 
individual or the pooled serum from several normals. The latter con- 
stitutes the control or standard measure. A capillary pipette is made 
and marked about an inch from the end. With a rubber teat the 
leukocyte suspension is sucked up to this mark, then a small bubble is 
allowed to enter the tip, then the bacterial suspension is sucked up to 
the mark, a bubble allowed to enter and last the serum drawn up to the 
mark. We now have three equal quantities of cells, bacteria and 
serum, separated by bubbles. The contents are then mixed by blowing 
out the contents on a slide and sucking it up, repeating this several 
times. Bubbling must be avoided. The contents, sucked well up into 
the ttibe, the tip is sealed in the flame, and the tube incubated at 37° C. 
for twenty minutes or longer Fig. 10, d and e. The tip is then nicked 
with a file and the contents again mixed, a drop placed on a slide, a 
smear prepared, using another slide, or cigarette paper as a spreader. 
This is then fixed and stained and examined with the oil-immersion lens. 
The leukocytes are more numerous along the edges of the smears. The 
average number of bacteria per leukocyte is determined by counting 
the contents of fifty or preferably one hundred cells. This is done 
with the normal or control serum and with the serum for test. The 
result is expressed by the opsonic index thus: 

5 per leukocyte-test serum. _ . . , 

Opsonic index, 0.5. 



10 per leukocyte- control serum. 



Before carrying out this method the bacterial suspension must be 
standardized so that not more than five to ten bacteria per leukocyte 
will be taken up in the time of incubation. This is done by preliminary 
tests with the suspension and dilutions of the suspension. 

Applications of the Opsonic Determinations. — Wright advocated the 
method as a means of control of vaccine therapy. Where vaccines are 
injected, Wright states, there "supervenes a negative phase where there 
is a diminished content in protective substances. This is succeeded 
by a positive phase. This inflowing wave of protective substances 



OPSONINS AND PHAGOCYTOSIS 



55 



rapidly flows out again, but leaves behind in the blood a more or less 
permanently increased content of protective substances. When a small 
dose of vaccine is given the negative phase may hardly appear but 
the positive phase may be correspondingly diminished. Where an 
unduly large dose of vaccine is inoculated the negative phase is pro- 
longed and much attenuated. The positive phase may in such a case 
make default. It will be obvious that, if we, in the case of a patient 
who is already the subject of a bacterial invasion, produce by the 
injection of an excessive dose of vaccine a prolonged and well-marked 
negative phase, we may, instead of benefiting the patient, bring about 
conditions which will enable the bacteria to run riot in his system. " 

" Now consideration will show that we may obtain, according as we 
choose our time and our dose wisely or unwisely, either a cumulative 
effect in the direction of a positive phase or a cumulative effect in the 
direction of a negative phase. We may in other cases, by the agency 



1.7 
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.8 

.6 
.5 


































































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Fig. 11. — Opsonic curve, showing the slight immediate rise and the later negative and 
positive phases following inoculation. The changes here are more regular than generally 
occurs. 

of two or more successive inoculations, raise the patient by successive 
steps to a higher level of immunity, or, as the case may be, bring down 
by successive steps to a lower level. We can select the appropriate 
time and dose with certainty only by examining the blood and measur- 
ing its content in protective substances in each case before reinocu- 
lating" (Fig. 11). 

The reasons for the discontinuance of this method are several: (1) 
the relative inaccuracy of the method; (2) the fact that almost equal 
differences can be observed in normal or diseased individuals from 
day to day without regard to injections of vaccines; (3) injections 
were based, not on the index at the time of injection, but of the previous 
day because of the exigencies of the opsonic method; (4) the develop- 
ment of a negative phase is apparent, not real; (5) equally satisfactory 
results were obtained, controlling dosage by the degree of focal and 
systemic reaction. 



56 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

The determination of the opsonic content of immune horse serum to 
be used for therapeutic purposes has been very generally employed, 
especially for the standardization of antimeningococcus serum. The 
method is far from satisfactory for the reasons given and is no longer 
employed as a routine test. The determination of the presence of an 
increased opsonic content has been utilized to a limited extent as a 
diagnostic procedure. On the whole the method is only applicable 
to special investigative work and the results must be scrupulously 
controlled and the results verified by many repetitions of the test. 

Use of Antibacterial Serum for Therapeutic Purposes. — Sera having 
a high antibody content also show considerable protective value on 
animal injection. Likewise, therapeutic value is indicated for such 
sera in that they prevent or delay the death of experimental animals 
even when the serum is administered after the infecting dose of bacteria 
is given. The relative effect, however, is directly proportionate to the 
shortness of time which elapses between infecting and serum dose. This 
is partly due to limitations of such animal experimentation. These 
are imposed by the fact that we are not reproducing the natural disease 
in the animals but causing an infection, the only reliable criterion of the 
severity of which is the death or recovery of the animal. Because of 
these facts antibacterial sera have been utilized in man for both prophy- 
lactic and therapeutic purposes. 

Titration of Sera. — Standards.— The methods employed and the 
standards adopted, vary to a great extent, as the problem involved is 
much more complex than with toxin-antitoxin methods. The methods 
possible of application are dilution titration of the antibodies, aggluti- 
nins, opsonins and bactericidal content and the determination of the 
protective value when injected with cultures. The agglutinin content 
is chiefly of value with typhoid and dysentery, although the content in 
these antibodies may decline after prolonged inoculation without, so 
far as we know, a coincident fall of other antibodies. The agglutination 
reaction is of some value in determining the probable antibody balance 
where several or many types of strains are employed as with dysentery 
and meningococci, this being the guide as to the pro-rata amounts to 
be injected into the horses. The value of this method is naturally 
influenced by the tendency of the horse to produce common agglutinins. 
Opsonic determination is only of comparative value. It cannot be used 
as a basis for a standard as it is open to serious error and variations 
beyond control. The bactericidal titration has found only limited 
application. The complement-fixation reaction has been of value in 
titrating meningococcus serum; and a rough standard that not more 
than 0.002 c.c. shall be required to give complete fixation, using a 
mixed antigen, is employed in several laboratories. The protective 
value of meningococcus serum, using white mice (Hitchens and Robin- 
son 1 ), promises to be of value. For pneumococcus serum protective 
experiments with white mice offers the best method. According to 

1 Jour. Immun., 1916, i, 345 and 355. 



TITRATION OF SERA 57 

Cole, 0.2 c.c. of serum should protect against 0.1 c.c. (Type I) or 0.01 
c.c. (Type II) of a broth culture (of which 0.000001 c.c. kills mice) 
when culture and serum are injected simultaneously. Protection 
experiments can also be applied to streptococcus serum, although 
difficulties may be encountered in raising the virulence of the 
strains. 

On the whole the methods are far from satisfactory, titration of one 
antibody does not necessarily give us any information as to the content 
in other antibodies. Where many representative types are employed, 
the balance not only as regards one antibody, but possible variations 
in comparative content of different antibodies against the individual 
strains still further complicates matters, as well as insufficient knowl- 
edge of the actual immunological relationship of these strains. Pro- 
tection tests are satisfactory where the bacterium is truly septicemic for 
the test animal, less so where invasion is less marked (meningococci) 
and of least value where death is due essentially to endotoxins. Pro- 
tection tests, furthermore, only give us information concerning the 
strain used, and in the case of meningococci, for instance, we know 
little as to the degree of cross-protection with strains having aggluti- 
native relationship. Furthermore, there is only partial knowledge as 
to the relation of the total antibody content to protection and finally 
to therapeutic effect in man. 

Bleeding. — Bleeding for therapuetic sera are made with trocar and 
rubber tube into 2-liter Erlenmeyer flasks having a large flat wire egg- 
beater to support the clot. After the flask is about half-full, it is tilted 
on the side where the wire is inserted. The flasks may be stood up 
after the clot is firm. The serum separating after twenty-four and 
forty-eight hours is drawn off with siphon. All operations must be 
aseptic. 

Serum. — The collected serum is placed in a sterile vessel and trikresol 
added, drop by drop, with vigorous stirring to prevent precipitation, 
until 0.4 per cent, is added. In two to three weeks, after which further 
fibrin separation usually ceases, it is passed through a Berkefeld filter 
to remove any contamination occurring at the time the trikresol was 
added. The trikresol will prevent any multiplication of the contamin- 
ants prior to filtration. Instead of. trikresol one may add several cubic 
centimeters of chloroform per liter and shake, the excess settles out 
with any separated fibrin and is avoided when the serum is drawn up 
in the blotting apparatus. The sera must be kept in the refrigerator 
at all times and tested to determine its sterility before being issued. 

Concentration. — This is not practised as it is with the antitoxins. To 
test the different fractions and determine which to use is, to a great 
extent, impracticable until we have better methods for standardization 
and a clearer knowledge as to what antibodies are essentially of thera- 
peutic value. 

Cross-protection and Strain Identity. — The error of assuming strain 
identity on the basis of insufficiently controlled protection tests is fre- 
quently heard. Thus, if antiserum A will protect against Strains A, 



5S ANTIMICROBAL OR ANTlPROTElN SUBSTANCES 

B, C, etc., this is advanced as proof of identity. As a matter of fact it 
is only an indication of group relationships. The following schematic 
presentation of the results of Avery will show this very clearly: 

PNEUMOCOCCUS PROTECTION TESTS. 

Variety of culture. 
Variety of antiserum. Type II. Subgroup Ila. Subgroup lib. 

Type II Protects Protects Protects 

Subgroup Ila .... No protection Protects No protection 

Subgroup lib .... No protection No protection Protects 

In other w T ords the reverse phenomenon must be observed before 
conclusions are drawn. The question arises: would even mutual pro- 
tection be complete evidence of identity? If this were encountered the 
relative degree of cross-protection which naturally should always be 
carefully controlled might reveal differences. Theoretically at least, 
there is no reason to believe that apparently complete mutual cross- 
protection might not occur with two closely related but not identical 
strains. If this is theoretically possible it again brings us to our previous 
theorem that antibody absorption is our ultimate criterion. This has 
been discussed primarily under agglutination, because agglutinin 
absorption is usually the expedient method since we can control the 
technic more easily and because quantitative estimations can be more 
easily and accurately made. The same principles, however, are appli- 
cable to the absorption of other antibodies. 

HYPERSENSITIVENESS. 

Enzymes and anti-Enzymes, Aggressins. 1 

In preceding pages we have considered the production of immu- 
nity through the introduction of antigenic substances. We have now to 
consider a phenomenon which seems at first to be the antithesis of 
immunity. Thus, if a very small amount of bacterial or other protein be 
injected into a guinea-pig, a change occurs so that while the first dose 
produces no noticeable reaction a second injection of the same protein 
given ten to fourteen days later will cause symptoms of shock or even 
death of the animal. This phenomenon Richet called "anaphylaxis." 
This reaction in the guinea-pig has been studied in detail with the hope 
that the evidence acquired would help explain somewhat similar phe- 
nomena encountered in infectious diseases as well as the reactions 
following the introduction of repeated injections of antitoxins or sera, 
ingestion of certain food or drugs (idiosyncrasies), etc. Furthermore, 
any reasonable hypothesis advanced in explanation of these phenomena 
would seem to apply to the development of the common symptoms 
(fever, etc.) of infections. 

1 For fuller discussion and bibliography see A. F. Coca: Hypersensitiveness, Tice's 
Practice ot Medicine. V. C. Vaughan and W. J. Vaughan: Protein Split Products in 
Relation to Immunity and Disease. 



H YPERSEXSl TIYEXESS 59 

The terminology as well as the classification of these altered reactions 
to foreign proteins is far from satisfactory on account of the many con- 
tradictory hypotheses advanced in explanation. It would seem wiser 
to limit the term anaphylaxis to the acute symptoms developing after 
an injection of protein, because of the sensitization induced by the 
previous injection or injections of the same protein, a phenomenon 
seen best in the experimentally induced condition in animals. One 
reason for this is that there is increasing evidence that this is a separate 
phenomenon. Another is that the use of the term for all the reactions 
seen in man following the administration of antitoxins and serums had 
led to undue fear of untoward reactions, as in the minds of most the 
term implies acute shock. 

Anaphylaxis in Guinea-pigs. — Twenty-five years ago Theobald Smith, 
Park and' others found that when an injection of horse serum was 
given to a guinea-pig which had been used for horse antitoxin test- 
ing some weeks before, striking symptoms developed and that fully 
half of the animals died in thirty minutes. Animals which had 
received no serum showed no reaction from the same dose. Rose- 
nau and Anderson and Otto studied this phenomenon and showed 
conclusively that the antitoxic content of the serum was not a factor, 
but that the symptoms were wholly due to the serum proteins. It was 
found that an incubation period was necessary before the pig became 
hypersensitive and that as this period became longer the larger the 
initial or sensitizing dose. Very small amounts of serum sufficed to 
sensitize, even as little as 0.000001 c.c. Larger doses (approximately 
1000 times the minimum sensitizing dose) are necessary to elicit symp- 
toms. The size of dose depends on the rapidity of absorption. Thus 
a small dose will kill when given intravenously; a larger dose is needed 
if injected intraperitoneally and still more if given subcutaneously. 
The rapidity of development and the extent of symptoms developing 
after the second injection depend on the sensitiveness of the animal and 
the size and mode of administration of the dose. The guinea-pig first 
shows restlessness, then scratches at the mouth, coughs and develops 
spasmodic or rapid breathing. Urine and feces are discharged. The 
guinea-pig then falls on its side, breathing becomes difficult or arrested 
and spasmodic or convulsive movements supervene. The convulsions 
are usually followed by the death of the animal. Associated with these 
symptoms there are a fall in temperature, a leukopenia, a diminution in 
complement in the blood, and a delay or loss of blood coagulability. 
On autopsy the lungs are markedly distended, due to stimulation and 
contraction of the smooth muscle of the small alveoli, thus retaining 
the inspired air. This explains the respiratory symptoms noted before 
death. The heart continues to beat for some time after death. The 
contraction of smooth muscle is due to peripheral irritation. 

In Rabbits.— It has been estimated that rabbits are x^oth as sensitive 
as guinea-pigs. Symptoms of anaphylaxis may be produced easily, 
but acute anaphylactic death occurs only irregularly. Several injec- 
tions of serum are needed to sensitize the animal. Shock is most 



60 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

constantly produced when 1 or 2 c.c. are injected at five-day intervals 
and then after three days giving daily intraperitoneal or intravenous 
injections of 0.2 c.c. for two weeks or more The shock injection 2 c.c. 
is given five days later by the intravenous route. The symptoms 
elicited are less marked than with the guinea-pig and the intense 
dyspnea is absent. Death is due to cardiac and vascular disturbance. 
The pulmonary arterial system is so contracted that perfusion of salt 
solution even under high pressure is impossible. 

Besides acute anaphylaxis, Arthus has demonstrated a peculiar local 
effect following repeated doses of serum. If several or more injections 
of serum are given a rabbit, subsequent subcutaneous injections will 
frequently cause severe local reactions which may result in local necrosis 
(Arthus's phenomenon). This is not a cumulative effect, as previous 
subcutaneous injections caused no reaction even when given in the 
same place, whereas the later reaction occurs wherever there is an area 
of injection. 

In Dogs. — Dogs may be sensitized with two injections of serum (first 
subcutaneous, second intravenous) five days apart. A shock dose of 
20 to 30 c.c. given intravenously several weeks later will cause symp- 
toms and death. Vomiting or retching and evacuation of the bowels 
are among the earliest symptoms. The circulatory disturbance is 
apparently due to engorgement of the liver resulting in a great accumu- 
lation of blood in this organ and in the portal vessels. This would 
account for the anemia and low pressure in the general circulation. 

Dependence of Symptoms on Contraction of Smooth Muscle. — Schultz 
has demonstrated that the hypersensitiveness of smooth muscle is the 
main factor in anaphylactic response. In the guinea-pig this is shown 
by the contraction of the bronchial musculature. In rabbits and 
dogs this bronchial phenomenon is not marked, possibly because 
the bronchi are relatively poorly supplied with muscle, but the cir- 
culation disturbances in the dog and the rabbit are explainable on the 
same basis. The cause of the disturbance is the same, though there is 
a difference in the site of action. This effect on smooth muscle can be 
demonstrated on excised muscular organs such as the uterus. 

Sensitization by Enteral Introduction. — In the preceding paragraphs 
sensitization by the parenteral administration has only been mentioned. 
Sensitization induced by feeding, has been reported by Rosenau and 
Anderson. Other observers have had contradictory results. It would 
seem that success depended on whether unchanged protein reached 
the large intestine, from which it can be absorbed. 

Passive Anaphylaxis. — In contrast to the active sensitiveness, hyper- 
sensitiveness of one animal may be transferred to another by the injec- 
tion of the blood or serum of the first animal. This is not only possible 
with animals of the same species (homologous, viz., guinea-pig to guinea- 
pig), but with animals of different species (heterologous, viz., rabbit to 
guinea-pig) . Hypersensitiveness is transferred to the offspring of sensi- 
tized mothers; thus, young guinea-pigs may be sensitive for five or six 
weeks or longer after birth. Hypersensitiveness to specific toxin cannot 



H Y PERSE N SI TI V EN ESS 6 1 

be passively transferred. There is no specific hypersensitiveness of the 
ordinary kind to exotoxins. 

Unless the anaphylactogen (see below) and the immune serum are 
injected together anaphylactic symptoms cannot be induced in a guinea- 
pig by the injection of antigen, until some time (four to six hours) after 
the immune serum has been given. 

In the rabbit and dog it may be induced immediately after injection 
of the immune serum. 

The Anaphylactogen. — This term is applied to the substance which 
induces the state of anaphylaxis. All evidence indicates that only 
proteins which can act as antigens may become anaphylactogens. The 
proteins may be of animal or plant origin, including microorganisms 
and their extracts. Such proteins must be alien to the animal injected 
or at least alien to his circulation. 

Probably the whole protein molecule is necessary to induce hyper- 
sensitiveness. Proteins split by digestion or chemical agents lose the 
sensitizing property. Heating diminishes or destroys the sensitizing 
action of proteins in proportion to the degree of coagulation caused by 
the heating. The ability to produce anaphylactic shock may be lost 
before the ability to sensitize, because minute residues of the original 
protein would still suffice for sensitization. Vaughan believes that the 
protein possesses a non-specific toxic portion and a specific sensitizing 
portion. He obtained two such fractions by treatment with an alcoholic 
solution of alkali. The sensitization by the one fraction could equally 
be used as an argument that all of the protein molecules had not been 
cleft. The anaphylactogen, at least with native proteins and bac- 
teria, is specific, that is, only the same protein which was used for sensi- 
tization will cause anaphylactic symptoms. This specificity follows, 
as a rule, the biological origin, as has been noted with other antigens. 

Similar Non-specific Phenomena. — The products of protein cleavage 
when injected intravenously in normal animals are toxic. An example 
has been noted, viz., that obtained by Vaughan. Peptone likewise 
causes the symptoms of anaphylaxis. Bordet showed that the addition 
of agar jelly to guinea-pig serum and subsequent incubation at 37° C. 
rendered the serum toxic. In fact, many substances, chloroform, col- 
loidal silica, kaolin and even distilled water, will render normal or 
immune serums toxic. This toxicity manifests itself by causing ana- 
phylactic symptoms. The same effect may be noted after intravenous 
injections of such substances, the toxification of the blood occurring in vivo. 

Anti-anaphylaxis or Desensitization. — If animals survive the second 
dose of protein they are for some days relatively very insensitive to the 
protein. The injection into the guinea-pig of one or more small doses of 
the specific protein during the period of incubation has the same effect. 
This condition of desensitization is only temporary, sensitization again 
developing after several weeks. The serum of an anti-anaphylactic 
animal does not confer this property to a second animal; in fact the 
opposite occurs, the second animal becoming passively sensitized. The 
injection of an immune serum (specific for the protein) prior to the dose 



62 ANTIMIt 'ROBAL OR ANTIPROTEIN SUBSTANCES 

of protein will interfere with development of anaphylactic symptoms. 
A relative resistance to anaphylaxis may also be induced by the injec- 
tion of non-specific substances, proteins, peptones, etc., as well as with 
drugs, atropin, chloral, etc. 

Theories of Anaphylaxis. — Two theories have been advanced which 
assume that the toxic agent is a digestion product. Vaughan believes 
that the first injection sensitizes the animal by stimulating the produc- 
tion of specific zymogen which when activated will cleave the protein 
on second injection, the products of this cleavage being toxic. The 
zymogen according to this conception would be an amboceptor-like 
antibody which would be activated by the complement. Friedberger 
maintains the same views based on his observations that the toxin, 
inducing anaphylactic shock, develops in test-tube mixtures of antigen 
and its antiserum; the term anaphylotoxins is used to designate the 
shock-inducing poison. 

This conception then involves the idea that amboceptor and comple- 
ment activity results in proteolytic cleavage. Jobling found no 
evidence that amboceptor and complement will cause proteolytic 
cleavage. Nor is there reason to believe that there is produced some 
other specific antisubstance having actual proteoclastic activity. To 
sustain his theory, Vaughan concludes that the anaphylotoxin and the 
poisons resulting from proteolytic cleavage are the same, because they 
cause the same physiological effect. By the same reasoning he would 
be forced to assume that the toxic product in a mixture of serum 
and a non-specific non-protein substance where no protein antigen is 
available for cleavage is again the same poison. Friedberger 's idea that 
complement is essential to the reaction is also untenable for similar 
reasons. 

Jobling in his earlier work met those objections by the hypothesis — 
that the digestion products come from the serum and not from the 
antigen. This digestion resulting from the depression or neutralization 
of the antitryptic substances which would allow the serum-protease to 
digest the serum. Non-specific substances as mentioned above would 
cause this effect because of their neutralizing action. Specificity could 
be assumed on this basis to be due to the fact that the antigen-antibody 
complex would possess this neutralizing action. 

Both digestion theories fail in our opinion to explain the quick 
response especially of excised smooth muscle. Dale employing the 
reaction of the uterine muscle, has questioned whether toxic digestion 
products could be produced within the time between contact of antigen 
and muscle response. The rate of reaction is equal to that of a per- 
formed protein poison such as histamin. Digestion theories fail to 
interpret the delay in passive sensitization of guinea-pigs 

Novy and De Kruif have elaborated a theory, drawing an analogy 
between the production of anaphylotoxin and the mechanism of blood 
coagulation. This latter results from the change of fibrinogen into 
fibrin through the so-called fibrin ferment. They assume the existence 
of a more or less labile matrix in the blood which is changed by a cata- 






HYPERSENSITIVENESS 63 

lyzer into anaphylotoxin. The two phenomena are similar, therefore, 
in that a labile substance undergoes rearrangement resulting in tauto- 
meric modifications, on the one hand the insoluble fibrin, on the other, 
the soluble anaphylotoxin. This theory assumes that the non-specific 
substances noted above give rise to the same poison as is active in 
specific anaphylaxis. The only difference is that the antigen-antibody 
complex is the catalytic agent in specific anaphylaxis. This theory 
also fails to explain all the phenomena, especially the delay in passive 
sensitization. It does seem to eliminate the doubtful aspects of the 
digestion theories. 

A moderate toxicity of the blood has been demonstrated by Novy 
for animals sensitized and shocked by relatively large doses of antigen 
or by non-specific agents. The question arises would this be so if the 
minimal shock-inducing dose had been used. Weil transfusing normal 
dogs with even the whole volume of dogs dying or dead of anaphylactic 
shock uniformly failed to demonstrate any increased toxicity. If the 
toxic products were formed in the circulating blood, one would expect 
to be able to demonstrate at least some toxicity. 

If the digestion theories or that of Xovy assumed the cell as the site 
of toxin production, the time factor raised by Dale would still be a 
difficulty. 

All the theories thus far given do not take into consideration the fact 
that the organs of an immune animal are hypersensitive although the 
animal as a whole is not. This as well as the fact that the injection of 
immune serum specific for the protein to be used will prevent anaphy- 
lactic shock, indicates strongly that an excess of antibodies in the 
circulating blood acts as a protective barrier, preventing the antigen 
from reaching the cells. 

Because of the facts given above, the opinion is gradually being 
adopted, that the site of the production of the toxic substances is in 
the cells. This is spoken of as the cellular theory. Many observers 
believe that the antigens combine with the cellular antibodies (sessile) 
and that the combination in some way injures the susceptible cells. 
Such a theory would be compatible with the delay in passive sensiti- 
zation, the latent period being assumed necessary for cellular com- 
bination by the introduced antibody. 

The question as to the antibody involved is not easily answered. 
The production of anaphylaxis in guinea-pigs in which complement is 
suppressed has been advanced as proof that complement is not involved 
in the reaction. The absence of demonstrable complement in the blood 
is not necessarily a demonstration of its absence in the cells. Most of 
the adherents of the cellular theory believe that the precipitins are 
involved in the reaction. This, at least, is not susceptible to direct 
proof. As we have seen, these antibodies are not easily produced in 
demonstrable amounts, and they are certainly not demonstrable in 
guinea-pigs sensitized with minute quantities of antigen. There is 
evidence, however, indicating that the capacity of serum to confer 
passive hypersensitiveness is proportionate to its precipitin content. 



64 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

The fact that the washed specific precipitates resulting from antigen- 
antiserum mixtures will passively sensitize guinea-pigs does not neces- 
sarily indicate that the precipitin is involved. The precipitate, as we 
have seen, will carry down other antibodies as well. If a cellular theory 
as outlined is accepted, the specific anaphylotoxin must be assumed to 
be distinct from the toxin produced in the test-tube by admixtures of 
specific antigen and antiserum by serum and non-specific substances, 
as well as from the products of protein digestion. A theory that the 
first injection causes a physical change in the cells, rendering them 
hypersensitive to a second injection has been advanced. 

On the whole, one cannot but conclude that no hypothesis thus far 
advanced is satisfactory. However, the value of these hypotheses as 
stimulants to experimental observation should not be underrated. 

Anaphylaxis and the Symptoms of Infection. — Vaughan's theory of 
anaphylaxis has received such wide attention and acceptance because 
it seemed to explain in a satisfactory manner the toxic symptoms of 
infection caused by bacteria producing no demonstrable extracellular 
poisons. According to this conception the digestion products of the 
microbal protein would be the active agent. Carrying this conception 
further, the poison would be non-specific in character, being developed 
in the cleavage of any protein. Vaughan has shown that fever and the 
accompanying symptoms noted in all infections can be reproduced by 
the injection of protein cleavage products, the character of the fever 
depending on the size and number of doses injected. The hypothesis 
of Friedberger is very similar. The modified theories of anaphylotoxin 
production of Joblin or that of Novy could be similarly adapted as an 
explanation. Although there is strong doubt that digestive products 
play any role in the development of the anaphylactic reaction, the 
objections raised would not hold true in relation to the symptoms of 
disease. In the absence of more opposing evidence it seems probable 
that digestion products, although not due directly to antibody action 
may play a partial role at least in the production of disease symptoms. 
In this connection, however, it must be remembered that the mere 
autolysis in water of some microorganisms, for instance, the pneumo- 
coccus, will yield an acutely toxic substance. The question arises 
again, however, are such substances directly or indirectly poisonous. If, 
as seems implicated in such hypotheses, antibodies are necessary for 
the development of the poison it is difficult to understand the symptoms 
associated with very acute or fulminating infections. 

Toxin Hypersensitiveness. — Because of certain phenomena, some 
investigators believe that there develops at times a hypersensitiveness 
to soluble or exotoxins, comparable to some extent with the hyper- 
sensitiveness to bacterial protein. It has been conclusively demonstrated 
that, if an M. L. I), dose of toxin is divided into ten or twenty parts 
and one part injected every day or every other day, death will take 
place when about 40 to 60 per cent, of the M. L. D. dose is given. It 
has also been observed that if several small doses of toxin are given, 
fifteen to twenty days later, additional doses of as little as xlyo^h M. L. 






H TPERSEXSI TI T 'EXE.-.- 65 

D. will cause death. Suggested explanations are that either certain 
cells stimulated by the previous injections have developed a greater 
avidity for the toxin or that some cells naturally possess a greater 
avidity. On either supposition these cells unite with a larger propor- 
tion of the toxin, when it is injected in small amounts. 

Behring has made the statement that horses under immunization 
possessing large amounts of antitoxin in their blood, showed hypersen- 
sitiveness to the toxins. These animals, however, did not develop 
symptoms of tetanus or the specific changes due to diphtheria toxin. 
depending on which was being used in immunization. Doerr. Pick and 
others have pointed out that as we never inject toxin in a pure state. 
the symptoms were most probably due to the associated meat extrac- 
tives peptone and products of bacterial autolysis present in the toxic 
broth. This is our opinion. We have immunized over 700 horses and 
have never encountered a reaction suggestive of toxin hypersensitive- 
fter antitoxin had developed. We have found that only those 
animals possessing no natural antitoxin will show such a phenomenon 
and they will no longer react in this way when antitoxin appears in 
the blood. This is true also for small animals. 

We have already referred to the long delay which intervenes between 
the injection of toxin and the development of antitoxin in the guinea- 
pig or rabbit. This seems to have misled many observers, thus Loewis 
and Meyer reported that small animals which have no natural anti- 
toxin will show no response to a single injection of a toxin-antitoxin 
mixture, but will respond with antitoxin development if a second dose is 
given some weeks later. Our own observations show that all animals 
will in time develop at least some antitoxin from a single dose. As has 
been pointed out. in the previous chapter, if antitoxin is normally 
present or if it has developed, a subsequent injection of toxin or of a 
toxin-antitoxin mixture will cause a quicker and greater response than 
in cases where no antitoxin is present. Hypersensitiveness of a differ- 
ent kind exists, therefore, in the sense that the ability of antitoxin 
production is increased. 

Hypersensitiveness in Man. — Phenomena of hypersensitiveness in 
man may be observed after both the enteral and parenteral introduction 
of many and varied substances. These inducing substances may be 
divided into two groups, antigenic and non-ant igenic, viz., those which 
stimulate and those that do not stimulate the production of demon- 
strable antibodies. The degree of response to such substances is 
largely personal idiosyncrasy and the symptoms, however diverse the 
agent, have a great deal of similarity. Coca ha- suggested the term 
gy, introduced by von Pirquet. be limited to describe these 
individual peculiarities. A special term would certainly be advisable 
if it is eventually proved, as much of the evidence now indicates, that 
even where the inducing substance has antigenic properties, the 
reaction is not due to antigen-antibody combination or at least that 
the antigenic property has no bearing on the reaction. 



66 ANTIM1CR0BAL OR ANTIPROTEIN SUBSTANCES 






Serum Read ion. — The untoward symptoms elicited in man by the 
introduction of scrums with or without antitoxins may be divided into 
those following the initial injection and those following the second or 
later injections. These reactions have nothing to do with the antibody 
content of the injected serum. 

Following the first injection three types of reactions may be noted: 
(a) collapse, with or without fatal outcome, (b) a symptom-complex 
called "serum sickness," (c) local necrosis. Each of these forms of 
response may follow the second or later injections. 

Collapse or Death. — This rare accident has been noted nearly always 
after the first injection. The symptoms develop quickly after adminis- 
tration. In about 1 to 20,000 primary injections of antitoxin, alarming 
symptoms develop; in about 1 to 50,000 injections death results. The 
symptoms are those of extreme dyspnea and collapse. The dose may 
be small, in one instance about 1 c.c. (500 units) of antitoxin being given 
subcutaneously. Kerley reports a case of known hypersensitiveness 
where the dose was gradually increased until 4 minims were given, this 
resulted in alarming shock. The individuals showing this type of reac- 
tion are commonly those subject to "hay fever, or asthma," develop- 
ing attacks especially in the neighborhood of horses. Nearly all of the 
children dying after serum shock are cases of "status lymphaticus." 

A chill more or less severe is observed in about 40 per cent, of the 
cases after the intravenous injection of low-potency antitoxin, even 
when injections are given very slowly and the material warmed to the 
body temperature. In the Willard Parker Hospital the routine 
administration of antitoxin by the intravenous method has revealed 
that this probably depends on some special form of the protein, 
possibly upon a fine flocculent precipitate. With the best product 
less than 1 per cent, of intravenous injections produce a chill. 

In some instances the intravenous administration of antitoxin or 
serum, several weeks or longer after an initial injection, which cause 
no marked reaction, has resulted in alarming symptoms of collapse. 
This effect almost never follows a second subcutaneous injection. In 
other instances, frequently repeated intravenous injection of serum has 
developed instead of a desensitization a hypersensitiveness so marked 
that even small amounts of serum woud give a sharp reaction. Such 
conditions are relatively very infrequent. 

Serum Sickness. — The incidence of this type of reaction varies widely 
in different series of cases, from 10 to 60 per cent, or more. The size of 
dose will influence the percentage incidence. Because of the lower . 
protein content and also because of the heating, the concentrated glob- 
ulin preparations of antitoxin cause a relatively low incidence. Follow- 
ing the first injection of serum or antitoxin there is an incubation period 
varying from three hours to twenty-four days. More commonly the 
period ranges from three to twelve days. The symptoms are primarily 
a skin eruption, edema, slight albuminuria, variable both in incidence 
and in degree, enlargement of the lymph nodes with pain and tenderness, 
and pain in the joints. The eruption is very variable in character, A 



H Y PERSE N SI TI V EN ESS 67 

local eruption appears earlier than the general eruption. On the second 
or later injections, the period of incubation may be absent or shortened 
"immediate or accelerated reaction," although this does not always 
occur. This condition is not serious, and in the many instances given 
no greater discomfort than any itching rash. Some samples of serum 
or antitoxin uniformly cause a skin eruption (scarlatinaform) earlier 
than others. The longer incubation periods are more frequently 
followed by urticarial rashes. It would seem from this that there 
were different reaction-inducing substances in serum or antitoxin. 

Von Pirquet and Schick who have studied this condition in detail, 
believe that the reaction is due to antigen-antibody combination. 
They point out that the average incubation period coincides with the 
time of first appearance of precipitins in experimental animals. Like- 
wise, they believe that the immediate or accelerated reactions following 
later injections are explained by the presence of developed or develop- 
ing antibodies. This explanation, however, does not include the fairly 
common occurrence of a short incubation period. There is no parallel- 
ism between the presence of demonstrable precipitins in human beings 
and the appearance or severity of the reaction; in fact, precipitins 
may be present without allergy. 

Local Reactions. — In very rare instances the primary injection of 
antitoxin leads to local necrosis. Although this occurs with extreme 
infrequency it should be a warning against injection under the breasts. 
When repeated injections are given, a final subcutaneous injection 
somewhat more frequently results in a sharp local reaction which may 
go on to necrosis. This may occur not only with serum, but also with 
rabies vaccine. The resemblance of this form of reaction to the Arthus 
phenomenon is marked. The necrosis is not due to bacterial contami- 
nation but the necrotic area may become infected and serious or fatal 
results ensue. 

Desensitization to Serum. — Instances are noted with some frequency 
where first injections have caused reactions and following injections 
given several days or weeks later have produced little or none. This 
would seem to indicate a desensitization. As already noted, different 
batches of bactericidal or antitoxic serum will vary widely in their rash 
and temperature-producing qualities, and this may have been a factor 
in the development or non-development of symptoms. The administra- 
tion of small doses of serum, prior to a first injection or prior to subse- 
quent injections of those known to be sensitive, has not the regularity 
of desensitization noted in experimental animals. The observation of 
Kerley already noted is an example of such failure. Divided doses may 
fail to give a reaction or repeated small doses may apparently induce 
a tolerance, but this is no proof that we are inducing the mechanism of 
desensitization so uniformly producible in experimental animals. 

Prevention of Serum Reactions. — Such individuals as give a strongly 
suspicious history may be tested cutaneously for evidences of hyper- 
sensitiveness. The appearance of a wheal indicates that the person will 
show a fairly immediate serum reaction, such as rise of temperature or 



68 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

urticarial rash, but is no indication of the probable severity. The 
absence of a skin reaction indicates, but does not prove that there will 
be no reaction. The safest procedure,. however, is to inject the serum or 
antitoxin in divided doses every twenty to thirty minutes starting with 
0.1 c.c. and increasing the dose by 0.1 c.c. until symptoms are elicited 
or until sufficient is given. If symptoms develop one can attempt the 
repetition of smaller doses which had not caused symptoms. Where 
serum is to be administered intravenously, dilution and exceedingly 
slow administration at the beginning will help to avoid unfortunate 
results. Intraspinous injections should also be given slowly, especially 
the initial portion in those comparatively recently injected. 

The introduction of serum intravenously or intraspinously in those 
with the evidence of the extreme forms of hypersensitiveness should 
not be undertaken unless urgently required. 

Treatment of Developed Shock. — Hypodermic injection of epinephrin 
or atropin will usually relieve the less severe attacks. In extreme 
collapse artificial respiration may be tried. 

Allergy to Foods, Pollens, etc. — Rashes and other forms of reaction 
are commonly exhibited by a small percentage of individuals after the 
ingestion of a specific food. This may follow eggs, certain meats, fish, 
fruits, etc. The inducing substances may or may not be antigenic in 
character. Hay fever is an example of mucous membrane hypersensi- 
tiveness. Such individuals may show skin sensitiveness or develop 
rashes or other symptoms when the inciting substance is injected. Such 
hypersensitiveness may be toward pollens, dust from hair or skin of 
animals. The experimental work with pollen extracts seems conclu- 
sively to demonstrate that the inducing substances are not antigenic 
in character, viz., they do not stimulate antibody production nor will 
they sensitize experimental animals. Hay fever (and probably food 
allergy) is not due to sensitization of the individual but to an inherited 
predisposition. The hypersensitiveness to a specific agent is not neces- 
sarily inherited. 

The repeated use of small doses or high dilutions of substances 
involved in these reactions, will develop an increased tolerance. This 
is only relative and is not comparable to the regularly induced and 
quantitatively greater resistance of desensitized animals. 

Similar hypersensitiveness is shown in varieties of dermatitis due. to 
poison-ivy, sumac, etc. 

Drug Allergy or Idiosyncrasy. — Although toxic in larger amounts, the 
allergic symptoms follow a dose or doses, which are not appreciably 
toxic for most individuals. The symptoms elicited are evidently due 
to idiosyncrasy as they are different from those obtained with larger 
and uniformly toxic doses. The agents involved are various, including 
mercury, salvarsan, iodids, quinin, morphin, antipyrin, salicylic acid, 
turpentine, sandalwood oil, etc. The common symptoms are fever 
with or without chill, skin eruption, local edema or gangrene at the site 
of injection, swelling of the joints and lymph nodes. 

As has been noted most of the phenomena of allergy to serums, etc., 



HYPERSENSITIVENESS 69 

have much in common in their symptomatology. We have no evidence 
that the basis of these reactions is an antigen-antibody reaction, a 
hypothesis, which seems to be required in specific anaphylaxis. The 
dominant fact in human allergy is rather that of idiosyncrasy. In only 
a small number of cases has a condition been noted resembling anaphy- 
laxis, viz., local necrosis after repeated injections, and symptoms of 
collapse after a second injection. These may have been actual anaphy- 
lactic reactions. We have no reason to believe that anaphylaxis could 
not be induced in man as in other animal species. To elicit actual 
anaphylactic shock, however, the dose would have to be relatively 
large, even if man were as easily sensitized and shocked as is the guinea- 
pig, which is extremely unlikely. The usual dosage in man is much 
lower per body weight than necessary to cause shock in the guinea-pig. 
In the case of intravenous or intraspinous injections we cannot ignore, 
however, the factor of quick absorption. 

Hypersensitiveness and Infection. — In many infections there devel- 
ops in variable degree a hypersensitiveness to the substance or products 
of the infecting type. The most marked examples of this are noted in 
infections due to the tubercle and to the glanders bacillus. Tuberculin 
which consists of the soluble products found in a broth culture of the 
tubercle bacillus will serve as an example for discussion. 

Tuberculin is only toxic for an infected animal, that is, infection 
results in hypersensitiveness. This hypersensitiveness is shown by 
the skin, the mucous membranes or by a systemic as well as by a focal 
reaction (site of lesion) when injected in sufficient doses. If the dose 
injected be sufficiently increased, death of the sensitive animal is 
caused. The substance or substances involved are highly resistant to 
heat, specific, but not anaphy lactogenic. A relative tolerance can be 
induced in the tuberculous animal by gradually increased doses. 
The substance • involved is different from all known anaphylactogenic 
substances and animals cannot be rendered hypersensitive by its 
injection. The proteins of the tubercle bacillus, however, are anaphy- 
lactogenic, but the hypersensitiveness to these, which can be induced 
in normal animals, is a distinctly different phenomenon. The mechan- 
ism of the tuberculin reaction is obscure. 

A skin reaction is elicited in a considerable proportion of cases of 
syphilis by the intracutaneous injection of "luetin," an emulsion of 
the Treponema pallida. Similar indications of hypersensitiveness are 
noted in typhoid fever, or following the injection of typhoid vaccine by 
the ophthalmic or cutaneous method of introduction. Positive skin 
reactions have also been elicited by the gonococcus and also by some of 
the fungi. These reactions are relatively specific. 

The Practical Value of the Skin Reactions. — Of those other than that 
of tuberculin is materially reduced because of the relatively frequent 
occurrence of non-specific skin hypersensitiveness, which leads to con- 
fusing reactions. The generally advanced explanation is that a specific 
immune body antigen complex is formed and this subjected to digestion 
by the local cells leads to the development of toxic products or to a 



70 ANTIMICROBAL OR ANTIPROTEIN SUBSTANCES 

neutralization of the antiferment and digestion of the host's proteins. 
As the reaction develops relatively slowly, such explanations may be 
warranted. The reactions described, however, may not be due in some 
instances at least directly to the protein per se. Some secretion product 
which we cannot identify may be involved. With our present knowl- 
edge we are not justified in assuming an identity in the nature of these 
reactions and that of tuberculin, the active principle of which is dialy- 
zable, and apparently non-protein in nature. There is reason to believe, 
however, that the tuberculin in itself does not cause the reaction. The 
site of infection is much more sensitive to its action than are other 
areas. It would seem as it something were elaborated in the lesion 
which was a contributing agent. Many believe this to be an antibody 
and explain focal and the local reactions are due to a tuberculin plus 
antibody complex. We have little if any direct evidence for this 
assumption. 

Hypersensitiveness and Immunity. — -Jenner observed the more rapid 
appearance of a reaction following vaccination after a previous vaccinia. 
This observation has been studied by others and the evidence indicates 
that such an accelerated response is an indication of immunity. In the 
case of tuberculin, the reaction is also indicative of immunity to reinfec- 
tion. The disappearance of the reaction in a person with a latent lesion, 
during measles for instance, is not infrequently followed by extension 
of the lesion and tuberculous disease. Gay attempted to show that the 
appearance of a positive skin reaction to typhoidin was an indication of 
immunity to typhoid fever. This at least is not absolute, as the reaction 
is absent or disappears at a time after infection or vaccination when 
immunity is known to still exist. 

Because of the immunity-index character of the tuberculin reaction 
and the accelerated reactions observed in vaccinia, the conception 
that active immunity is basically a sensitization of the body cells has 
been advanced. This sensitization of the cells it is believed, is due 
to an acquired temporally and quantitatively exaggerated ability of 
response, the acquisition of this capacity being due to the stimulus 
of the immunizing agent. The basis of this ability we may conceive 
as due to the persistence of cellular antibodies (sessile). Stimulation 
may result also in the release of the antibodies as well as a rapid repro- 
duction. In the case of antitoxic immunity this is actually demon- 
strable. In the case of the antimicrobal type of immunity the results 
of injections of vaccines in immune individuals indicates that the 
antibody response is greater in immune than in the normal individual. 
The results of some observers have shown striking differences. Other 
observers have obtained very much less marked results. Non-specific 
factors are involved to some extent in this difference. The injection of 
a non-specific vaccine according to Jobling will cause a dispersion or 
release of preformed antibodies, thus increasing the blood content. 
Gay attempted to show that immune typhoid rabbits responded with 
a specific leukocytosis, that is, a specific cell-production stimulation 
resulted when injected intravenously with typhoid vaccine. Mc Williams 
was unable to verify these results. 






ENZYMES AND ANTI-ENZYMES 71 

ENZYMES AND ANTI-ENZYMES. 

Microbal Enzymes. — Pathogenic bacteria have enzymes which are 
necessary to their nutrition. When grown in media we find evidence 
of their action in proteolytic or carbohydrate cleavage or both. 
The degree of influence of such products in infection is not known. 
Certain bacteria secrete enzymes which are capable of digesting other 
bacteria such as pyocyanase secreted by the B. pyocyaneus. This 
product has been utilized for therapeutic purposes especially in 
localized infections. 

Enzymes (Ferments) of the Host. — Man and other animals possess 
digestive ferments not only in the intestinal canal but also in the body 
cells and fluids. As we have no evidence that proteins, microbal or 
other, are split by antibody-complement action we must look to these 
non-specific enzymes as the means by which the body disposes of paren- 
terally introduced proteins. At least we are forced to this assumption 
unless we can demonstrate the development of specific enzymes for 
the introduced material. The apparent demonstration of this by 
Abderhalden is rendered very doubtful by the contradictory evidence 
of other observers. In some instances, the observations as to specificity 
of reaction seem conclusive, but this specificity may be due primarily 
to specific antibody action, the digestion being a secondary non-specific 
phenomenon. As we have seen under anaphylaxis the source of the 
digestion products may not come from the foreign protein but from 
the proteins of the host. 

Antdenzymes (Antdferments) of the Host. — These substances can be 
demonstrated in the blood serum and are apparently the means by 
which autodigestion is prevented. According to Jobling and Peterson 
the antitryptic action of blood serum is due to the lipoids. Under 
anaphylaxis we considered the hypothesis that these substances may 
have a direct bearing not only on the phenomenon of anaphylaxis but 
also on the development of disease symptoms. If Jobling's hypothesis 
be accepted the bacterial products alone or combined with their 
specific antibody will neutralize the antienzyme leading to the develop- 
ment of "serotoxin" by the action of the serum protease. 

There is another phase which seems equally important. Bacteria 
seem to resist ferment action because of their lipoid content. Their 
limiting membrane is supposed to be lipoidal in character. This resist- 
ance is enhanced when bacteria are treated with lipoids. This would 
seem to explain both the resistance of the tubercle bacillus to digestion 
as well as the peculiar caseation of tuberculous lesions. The large 
amount of lipoids in the bacilli serves to inhibit the ferments liberated 
by disintegration of the tissue cells. The balance of enzyme and anti- 
enzyme is apparently a factor in the effects obtained in non-specific 
protein therapy (see under Vaccines). 

Aggressins — Virulins. — Welch has offered the hypothesis that bacteria, 
like the cells of the host, react, with the production of protective anti- 
bodies which limit or prevent the action of the host's curative median- 



72 ANTIMICROBAL OR ANT1PR0TEIN SUBSTANCES 

ism. Such adaptions would then underlie the characteristics of patho- 
genicity and virulence and explain the phenomena of bacterial resist- 
ance already described. 

Antiblastic Immunity. — This term was introduced by Ascoli to define 
the inhibitive action of immune serum on the metabolic processes of 
bacteria. Because of his failure to demonstrate a bactericidal or 
opsonic action in vitro, he believed that the activity of antianthrax 
serum resided in its antiblastic capacity, evidenced in one way by 
inhibition of capsule formation. Prior to his observation von Dungern 
and others observed similar inhibitive phenomena with immune sera, 
viz., restraint of pigment production by B. pyocyaneus, of proteolytic 
emzyme action by staphylococcus. In the latter case immune serum 
neutralized the enzymes obtained from the cocci, indicating that an 
antienzyme antibQdy was involved. Dochez and Avery have more 
recently studied this phenomenon with antipneumococcus serum. 
Although antipneumococcus serum fails to cause bacteriolysis, it will 
inhibit multiplication for a certain period of time. This without 
further analysis is apparently due directly to antienzyme action or 
interference with the utilization of carbohydrates and nitrogenous com- 
pounds. A closer analysis (Blake 1 ) indicates that the effect is due to 
agglutination, thus preventing the diffusion of the cocci throughout the 
medium and therefore diminishing the degree of utilization of foodstuffs. 
It is questionable how far the inhibition of special functions interferes 
with the infectious power of bacteria, especially when it is demon- 
strable that multiplication takes place in spite of such suppression. 

1 Jour. Exper. Med., 1917, xxvi, 563. 



CHAPTER III. 

PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES. 

By WILLIAM H. PARK, M.D. 

INFLUENZA AND THE CONTROL OF EPIDEMICS DUE TO INFEC- 
TIONS INTRODUCED THROUGH THE RESPIRATORY 
MUCOUS MEMBRANES. 

Influenza is an infectious disease characterized by great prostration 
and often inflammation of the mucous membranes, particularly of the 
respiratory tract. It is very doubtful whether what we call influenza 
is really an entity. 

Influenza prevails without regard to climate. It occurs sporadically, 
in epidemics and in great pandemics. The sudden eruption of epi- 
demics in localities from which the disease has been long absent, and 
where there has been no known new importation of infection, may be 
explained by assuming that the infectious agent, whether some special 
virus or merely some one of the microorganisms causing inflammation of 
the mucous membranes, has been brought in by a carrrier from outside 
or has remained attenuated in the respiratory or conjunctival secre- 
tions for years, and then becomes through some change in conditions 
virulent again when under favorable circumstances it may communicate 
infection to others and gain a further virulence which starts a continental 
or world-wide infection. A committee of the American Public Health 
Association of which I was a member brought together in a brief form the 
results of the experience derived from the last pandemic. The more 
important portions are given below in full. This report is not only of 
interest with respect to handling an influenza epidemic, but it considers 
measures applicable to controlling all infections of the respiratory tract. 

The present epidemic is the result of a disease of extreme communi- 
cability. So far as information available to the committee shows, the 
disease is limited to human beings. 

The microorganism or virus primarily responsible for this disease 
has not yet been identified. There is, however, no reason whatsoever 
for doubting that such an agency is responsible for it. 

While the prevailing disease is generally known as influenza, and 
while it will be so referred to in this statement it has not yet been 
satisfactorily established that it is the identical disease heretofore 
known by that name, nor has it been definitely established that all 
preceding outbreaks of disease styled at the time " influenza" have 
been outbreaks of one and the same malady. 

There is no known laboratory method by which an attack of influ- 






74 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

enza can be differentiated from an ordinary cold or bronchitis or other 
inflammation of the mucous membranes of the nose, pharynx, or throat. 

There is no known laboratory method by which it can be determined 
when a person who has suffered from influenza ceases to be capable 
of transmitting the disease to others. 

Deaths resulting from influenza are commonly due to pneumonias 
resulting from an invasion of the lungs by one or more forms of strepto- 
cocci, or by one or more forms of pneumococci, or by the so-called 
influenza bacillus, or bacillus of Pfeiffer. This invasion is apparently 
econdary to the initial attack. 

Evidence seems conclusive that the infective microorganism or virus 
of influenza is given oft' from the nose and mouth of infected persons. 
It seems equally conclusive that it is taken in through the mouth or 
nose of the person who contracts the disease, and in no other way, 
except as a bare possibility through the eyes, by way of the conjunc- 
tiva or tear ducts. 

Prevention. — If it be admitted that influenza is spread solely through 
discharges from the noses and throats of infected persons finding their 
way into the noses and throats of other persons susceptible to the 
disease, then no matter what the causative organism or virus may 
ultimately be determined to be, preventive action logically follows the 
principles named below and, therefore, it is not necessary to wait for 
the discovery of the specific microorganism or virus before taking ^uch 
action. 

I. Break the channels of communication by which the infective agent 
passes from one person to another. 

II. Render persons exposed to infection more resistant, by the use 
of vaccines. 

III. Increase the natural resistance of persons exposed to the disease, 
by augmented healthfulness. 

I. Breaking the Channels of Communication. — (a) By preventing 
droplet infection. The evidence offered indicates that this is of prime 
importance. 

(b) By sputum control. The evidence offered indicates that the 
danger here is due chiefly to contamination of the hands and common 
eating and drinking utensils. 

(c) By supervision of food and drink. Evidence offered does not 
indicate much danger of infection through these channels. 

Details and practical methods possible for the limitation of infection 
through droplets, sputum, and food and drink are discussed later under 
special preventive methods. 

II. Immunization and Vaccines. — (See also the report on bacteriology 
on page 84.) 

In the present epidemic vaccines have been used to accomplish: 

1. The prevention or mitigation of influenza per se. 

2. The prevention or mitigation of complications recognized as due 
to the influenza bacillus or to various strains of streptococci and pneu- 
mococci. 



INFLUENZA AND THE CONTROL OF EPIDEMICS 75 

In relation to the use of vaccine for the prevention of influenza, the 
evidence which has come to the attention of the committee as to the 
success or lack of success of the practice is contradictory and irrecon- 
cilable. In view of the fact that the causative organism is unknown, 
there is no scientific basis for the use of any particular vaccine against 
the primary disease. If used, any vaccine must be employed on the 
chance that it bears a relation to the unknown organism causing the 
disease. 

The use of vaccines for the complicating infections rests on more 
logical grounds, and yet the committee has not sufficient evidence to 
indicate that they can be used with any confident assurance of success. 
In the use of these vaccines the patient should realize that the practice 
is still in a developmental stage. 

The committee believes that when vaccines are used experimentally 
for the purpose of determining their preventive or curative value, the 
following conditions should be complied with: 

1. The groups of vaccinated and unvaccinated persons should be 
sufficiently large and the actual number of persons in each group 
should be accurately known. 

2. The relative susceptibilities of the two groups should be equal, 
as measured by age and sex distribution, previous exposures to infection 
without development of influenza and a previous history as to recent 
attacks of the disease. 

3. The degree of exposure in each group should be practically the 
same in duration and intensity. 

4. The groups should be exposed concurrently during the same 
stage of the epidemic curve. 

m. Increased Natural Resistance of Persons Exposed to Infection. — 
Physical and nervous exhaustion should be avoided by paying due 
regard to rest, exercise, physical and mental labor and hours of sleep. 
The evidence is conclusive, however, that youth and bodily vigor do 
not guarantee immunity to the disease. 

The nature of the preventive measures practicable and necessary 
in any given community depends in a large part upon the nature of the 
community itself, as to population characteristics, industries, and so on, 
and upon the stage and type of the epidemic curve. For example, the 
measures to be adopted in a purely rural community would not be 
practicable or desirable in a large metropolitan area, nor would the 
measures desirable and feasible at the beginning or end of an epidemic 
be found those best adapted for the intervening period. The com- 
mittee has found it impossible, therefore, to lay down any rules for the 
guidance of all health officials alike in preventive measures. The most 
it 1ms been able to do has been to state certain general principles that 
in its judgment should underlie administrative measures for the pre- 
vention of influenza. The application of these principles to the needs 
of any particular community must be left for determination by the 
officers of that community who are responsible for the protection of its 
public health. 



76 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

The preventive measures recommended by the committee are as 
follows: 

A. Efficient organization to meet the emergency, providing for a 
centralized coordination and control of all resources. 

B. Machinery for ascertaining all facts regarding the epidemic: 

1 . ( Compulsory reporting. 

2. A lay or professional canvass for cases, etc. 

( \ Widespread publicity and education with respect to respiratory 
hygiene, covering such facts as the dangers from coughing, sneezing, 
spitting, and the careless disposal of nasal discharges; the advisability 
of keeping the fingers and foreign bodies out of the mouth and nose; 
the necessity of handwashing before eating; the dangers from exchang- 
ing handkerchiefs; and the advantages of fresh air and general hygiene. 
Warnings should be given regarding the danger of the common cold, 
and possibly colds should be made reportable so as to permit the send- 
ing of follow-up literature to persons suffering from them. The public 
should be made acquainted with the danger of possible carriers among 
both the sick and the well and the resultant necessity for the exercise 
of unusual care on the part of everybody with respect to the dangers 
of mouth and nasal discharges. 

D. Administrative Procedures. — 1. There should be laws against the 
use of common cups, and improperly washed glasses at soda fountains 
and other public drinking places, which laws should be enforced. 

2. There should be proper ventilation laws, which laws should be 
enforced. 

Since the disease is probably largely a group or crowd problem, the 
three following sub-heads are especially important. 

3. Closing. — Since the spread of influenza is recognized as due to 
the transmission of mouth and nasal discharges from persons infected 
with influenza, some of whom may be aware of their condition but 
others unaware of it, to the mouths and noses of other persons, gather- 
ings of all kinds must be looked upon as potential agencies for the trans- 
mission of the disease. The limitation of gatherings with respect to size 
and frequency, and the regulation of the conditions under which they 
may be held must be regarded, therefore, as an esssntial administra- 
tive procedure. 

Non-essential gatherings should be prohibited. Necessary gather- 
ings should be held under such conditions as will insure the greatest 
possible amount of floor space to each individual present, and a maxi- 
mum of fresh air, and precautions should be taken to prevent unguarded 
sneezing, coughing, cheering, etc. 

Where the necessary activities of the population, such as the per- 
formance of daily work and earning of a living, compel considerable 
crowding and contact, but little is gained by closing certain types of 
meeting places. If, on the other hand, the community can function 
without much of contact between individual members thereof, rela- 
tively much is gained by closing or preventing assemblages. 



INFLUENZA AND THE CONTROL OF EPIDEMICS 77 

Schools.— As to the closing of schools there are many questions to 
be considered. 

(a) Theoretically, schools increase the number and degree of contacts 
between children. If the schools are closed, many of the contacts which 
the children will make are likely to be out of doors. Whether or not 
closing will decrease or increase contacts must be determined locally. 
Obviously, rural and urban conditions differ radically in this regard. 

(b) Are the children in coming to and going from school exposed to 
inclement weather or long rides in overcrowded cars? 

(c) Is there an adequate nursing and inspection system in the school? 

(d) Is it likely that teachers, physicians and nurses can really identify 
and segregate the infected school child before it has an opportunity to 
make a number of contacts in halls, yards, rooms, etc.? We suggest 
that children suspected of having influenza and held in school buildings 
for inspection should be provided with and required to wear face 
masks. • 

(e) Will the closing of schools release personnel or facilities to aid in 
fighting the epidemic? 

(/) If schools are kept open, will the absence of many teachers lower 
the educational standards? 

(g) If a number of pupils stay at home because of illness or fear, will 
they not constitute a heavy drag upon their classes when they ret inn? 

(/?) If schools are closed, is there likely to be an outbreak in any case 
when they are reopened? 

Churches. — If churches are to remain open, services should be reduced 
to the lowest number consistent with the adequate discharge of neces- 
sary religious offices, and such services as are held should be conducted 
in such a way as to reduce to a minimum, intimacy and frequency of 
personal contact. 

Theaters. — As regards theaters, movies, and meetings for amusement 
in general, it seems unwise to rely solely or in great part upon the 
ejection of careless coughers. In the first place it is difficult to deter- 
mine who is a careless cougher, and after each cough, danger has 
already resulted. It seems, too, that the closing of theaters may have 
as much educational value as then use for direct educational purposes, 
etc. Discrimination as to closing among theaters, movies, etc., on the 
basis of efficiency of ventilation and general sanitation, may be feasible. 

Saloons, etc. — The closing of saloons and other drinking places 
should be decided upon the basis of the probability of spread of the 
disease through drinking utensils and the conditions of crowding. 

Dance Halls, etc. — The closing of dance halls, bowling rooms,, 
billiard parlors and slot-machine parlors, etc., should be made effective 
in all cases where their operation causes considerable personal contact 
and crowding. 

Street Cars, etc. — Ventilation and cleanliness should be insisted upon 
in all transportation facilities. Overcrowding should be discouraged. 
A staggering of opening and closing hours in stores and factories to 



78 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

prevent overcrowding of transportation facilities may be cautiously 
experimented with. In small communities where it is feasible for per- 
sons to walk to their work it is better to discontinue the service of local 
transportation facilities. 

Funerals. — Public funerals and accessory funeral functions should be 
prohibited, being unnecessary assemblies in limited quarters, increasing 
contacts and possible sources of infection. 

4. Masks. — The wearing of proper masks in a proper manner should 
be made compulsory in hospitals and for all who are directly exposed 
to infection. It should be made compulsory for barbers, dentists, etc. 
The evidence before the committee as to beneficial results consequent 
upon the enforced wearing of masks by the entire population at all 
times was contradictory, and it has not encouraged the committee to 
suggest the general adoption of the practice. Persons who desire to 
wear masks, however, in their own interests, should be instructed as to 
how to make and wear proper masks, and encouraged to do so. 

5. Isolation. — The isolation of patients suffering from influenza 
should be practiced. In cases of unreasonable carelessness, it should 
be legally enforced most rigidly. 

6. Placarding. — In cases of unreasonable carelessness and disregard 
of the public interests placarding should be enforced. 

7. Hosjntalization. — The theory of complete hospitalization is that, 
if all the sick were hospitalized the disease would be controlled. In 
certain somewhat small communities where hospitalization of all cases 
was promptly inaugurated the disease did come quickly under control. 
It must be recognized, however, that unless every infective person 
can be detected and identified as such and removed to the hospital 
before he has infected others, hospitalization cannot be depended upon 
to eliminate the disease. 

In general, home treatment is to be advocated where medical, nurs- 
ing and other necessary facilities are adequate, and where home treat- 
ment is not directly contra-indicated by the danger of infecting others. 
The hospitalization in any case, mild or severe, should be undertaken 
only when facilities for home treatment are inadequate with respect 
to medical and nursing care or otherwise. The objection to routine 
hospitalization of mild cases lies in the fact that patients not already 
suffering from secondary infections may acquire them by exposure to 
hospital cases already so infected. The objection to the routine hos- 
pitalization of severe cases lies in the danger to the patient necessarily 
incident in the transfer from home to the hospital. 

8. Coughing and Sneezing. — Laws regulating coughing and sneezing 
seem to be desirable for educational and practical results. 

9. Terminal Disinfection. — Terminal disinfection for influenza has 
no advantage over cleaning, sunning and airing. 

10. Alcohol. — The use of alcohol serves no preventive purpose. 

11. Sprays and Gargles. — Sprays and gargles do not adequately 
protect the nose and throat from infection, for the following reasons ; 



INFLUENZA AND THE CONTROL OF EPIDEMICS 79 

(a) So far as the knowledge of the committee extends, no germicide 
strong enough to destroy infective organisms can be applied to the nose 
and throat without at the same time injuring the mucous membranes. 

(6) Irrigation of the nose and throat to accomplish the complete 
mechanical removal of the infective organism is impracticable. 

(d) Their domestic use is liable to lead in families to a common 
employment of the same utensils. 

(e) The futility of sprays and gargles has been demonstrated with 
respect to certain known organisms such as the diphtheria bacillus 
and the meningococcus. 

Miscellaneous Considerations. — 1 . Colleges, asylums and similar 
establishments may with advantage enforce rigid institutional quaran- 
tine against the outside world, if they begin in the early stage of an 
epidemic, provided they are so located and conducted as to render the 
procedure reasonably likely to be effective, even temporarily; for even 
temporary success will postpone the appearance of the disease, if it 
appears at all, to a time when the patients will be more likely to be able 
to have adequate medical and nursing care. 

2. The recommended measures for control, even if they do not 
accomplish the desired end, should at least be instrumental in distribut- 
ing the epidemic over a longer period of time, which in itself is highly 
desirable. 

3. The statistics of the disease and the keeping of proper records are 
extremely important. The lack of knowledge regarding innumerable 
factors in reference to the disease makes all the more desirable complete 
case records, etc. 

4. The committee wishes to emphasize the need for the complete 
statistical study of the collected data on the mortality, morbidity, case 
fatality, duration, economic aspects, and therapeutics of the disease. 
Through the collection of the facts in a uniform manner, and through 
the analysis of such tabulated data, especially mathematical graduation 
and testing and study of the figures, important contributions to the 
natural history and typical characters of the disease may be expected. 
General principles as to the etiology, fatality and practical manage- 
ment of influenza may follow from the extensive survey of the epidemic 
in the statistical laboratory as well as from the intensive bedside 
observation of single cases of the disease. 

5. The measures recommended are calculated to be effective in the 
promotion of respiratory hygiene in general and particularly in the 
control of pneumonia and other respiratory infections. 

Administrative Measures for Relief. — The committee on administra- 
tive measures for relief would submit the following considerations as 
constituting a summary of the important measures for meeting epi- 
demic conditions: 

1. General Rules. — 1. Compulsory reporting. 

2. Isolation, by cooperation and education, to a point where it does 
not diminish the willingness of the physician to report. 



SO PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

3. Placarding would seem to be subject to the same limitations as is 
isolation. 

4. The closing of many agencies will release medical, nursing, and 
volunteer services for special influenza work. 

5. It may be necessary to grant authority and power to the health 
authorities to administer relief. 

II. Preliminary Measures. — 1. The listing and distribution of 
resources, including physicians, nurses, social workers, nurses' aids, 
clerks, domestics, laundresses, automobiles, chauffeurs, mask makers 
and volunteers of all kinds. 

All available publicity channels should be used to promote volunteer 
service. 

An appeal should be made for voluntary donors of human blood 
serum from convalescent influenza patients, to be held in readiness for 
use in treatment. 

2. The centralization of resources, under one control, with central 
and branch headquarters, the city being districted for medical, nursing 
and other work. 

The central headquarters should be ordinarily under the supervision 
of a board representative of the most important agencies concerned, 
the board's work to be administered through a manager (presumably 
the health officer) selected for his fitness. 

3. The service should be maintained on a twenty-four-hour basis, 
and a system of outgoing and incoming telephone service is essential. 

4. The local authorities should get and keep in touch with State and 
national agencies. 

HI. Current and Continuous Analysis of Case Situation.- — 1. In the 
smaller communities a canvass should be made of all physicians, solicit- 
ing information as follows: 

(a) Number of cases under care. 

(6) Number of cases needing hospital treatment. 

(c) Number of cases needing home nursing care. 

(d) Number of cases requesting medical service but not reached. 
This information will indicate the situation as regarding the need 

for emergency nursing and medical service, and should be acquired as 
fully as possible in larger communities, through various agencies such 
as a current lay or police canvass of homes, etc. The continuous 
classification of cases according to these groupings is of practical value. 

IV. Analysis, Augmentation and Organization of Principal Facilities. — 
(A) Field Nursing. — 1. Ordinarily nursing facilities utilized in general 
public health work should be diverted to meet the epidemic situation, 
and should be used on a district basis, with all other available facil- 
ities, under one supervision. 

2. Nursing assistants, volunteers, etc., should be used wherever 
possible in homes and institutions, .under expert supervision, after 
classification and assignment on a basis of minimum standards as to 
fitness, and such intensive training in the care of influenza and pneu- 
monia patients as may be feasible. 



INFLUENZA AND THE CONTROL OF EPIDEMICS 81 

3. From the standpoint of the patient, home treatment is to be 
advocated, if medical, nursing, disease preventive and other facilities 
are adequate. 

4. Restriction so far as possible through the pressure of public 
opinion should be brought against the unnecessary use of private 
nurses. 

5. Automobile transportation should be provided, and the nursing 
service used to encourage isolation and education. 

6. Special record forms are essential for this and the medical work, 
and a special subcommittee is prepared to meet this problem. 

7. Provision as to housing and care should be made for out of town nurses 

8. We recommend further training with reference to influenza for. 
all graduates of Red Cross home nursing courses and more extensive 
use of their services. This would necessitate frequent and careful 
registration (names, addresses and telephone numbers) and further 
information regarding personal health, age and ability and willingness 
to serve. 

(B) Emergency Medical Service. — 1. The medical service should be 
handled through the central office, the physicians being responsible 
to the central office, though perhaps assigned to district offices. 

2. In this emergency service there should be utilized all available 
physicians such as school and factory physicians, volunteers, practitioners 
on a paid basis, fourth-year medical students, etc. This service should 
cover all calls reported, as unreached by private physicians or received 
through other channels and should be coordinated with the special nurs- 
ing service, being provided with automobile transportation, machines 
being hired if necessary. 

3. The emergency medical service should be used to select cases 
needing hospital care. 

4. It may be feasible to institute a central clearing house in certain 
districts for private physicians' calls. 

5. An arrangement should be made through the medical licensing 
board for the granting of temporary permits to practice to reputable 
physicians from out of the State, at the request of the Central Influenza 
Committee. 

6. In some localities it may be feasible to district the local practi- 
tioner and to have him meet special calls on a part-time basis for 
adequate compensation. 

7. Certain of the relatively non-essential specialties should be dis-. 
couraged, and the physicians in those specialties urged to volunteer 
for emergency district work. This type of service may be operated on 
a pay or free basis. 

8. Presumably some effort should be made, through an authoritative 
medical commission, to suggest standard methods of treatment, and 
wise limitations as to therapeutic procedure. 

(C) Hospital Facilities. — 1. It is essential that the facilities, if 
possible, be kept ahead of the demand. A daily canvass should be 
made and data collected regarding available beds, medical and nursing 

6 



82 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

needs, domestics, food, cots, supplies, etc. A regular visit by an 
inspector will probably prove more effective than an attempt at tele- 
phone communication. 

2. Under most conditions a central clearing house, covering most if 
not all of the hospitals, is advisable for the admission of cases. Through 
this channel the severer cases may receive first consideration. Owing 
to constant changes in the hospital bed situation, the daily canvass of 
facilities may not be wholly depended upon; on the contrary, it may 
usually be necessary to telephone the hospital in order to make sure 
regarding the admission of a particular case. In any event the hospitals, 
if facilities are inadequate, should be impressed with the necessity 
for admitting only the most severe or needy cases, pay or free. Special 
hospital arrangements should be provided for pregnant women. 

3. It is advisable to add wards or tents or new equipment to existing 
institutions rather than to establish entirely new emergency hospitals. 
If practicable, certain hospitals may be urged to handle influenza cases 
exclusively. 

4. Non-emergency surgical and chronic medical cases amenable to 
home treatment should be dehospitalized. 

5. A convalescent home, if adjacent to the hospital, may serve for 
the care of mild and convalescent cases, thereby increasing the space 
in the hospital for acute cases, obviously involving an increase in the 
nursing facilities. 

6. A canvass of ambulance facilities should be made, ambulances 
being requisitioned with payment, or hired by contract, if necessary. 
Automobiles and motor trucks should be potentially mobilized for this 
purpose. Frequently military equipment may be used if accessible. 

V. Social and Relief Measures. — 1. The central office should keep the 
family advised regarding the patient, thereby saving telephone calls, 
trolley fares and worry on the part of the family, and thereby increasing 
the willingness for hospitalization. 

2. Volunteer workers such as Red Cross volunteers, teachers, rela- 
tives, etc., should be placed in care of families where the responsible 
members are dead or hospitalized, this service being under expert social 
supervision, and the families in touch with the supply system. Super- 
vision of placed-out children is also necessary. 

3. Homes should be investigated before patients are discharged into 
them, when destitution or other untoward circumstances are apparent. 

4. Precaution should be taken that institutions and families too 
busy with the influenza situation to look after their own needs, are 
covered by the general relief measures. 

5. Ordinary charitable relief should be handled through the routine 
agencies, the service coordinated with the other epidemiological 
measures. Churches, lodges, etc., should be urged to handle their own 
cases, in order to relieve the pressure on the central agency. Aid 
should be immediate, without protracted investigation. 

6. Recreation facilities (motoring, etc.) should be provided for the 
physicians and nurses while off duty. 



INFLUENZA AND THE CONTROL OF EPIDEMICS 83 

VI. Food. — 1. Available central cooking facilities should be used so 
far as is necessary, such as the dietetic equipment in high schools, 
normal schools, colleges, etc., with a delivery system to families and 
institutions in need. 

2. Individual families should be encouraged to cook additional 
amounts, the same to be delivered to central diet kitchens for distribu- 
tion, a standard list of prepared foods needed being devised and adver- 
tised, with recognition of racial customs and preferences. 

3. It may be necessary to establish canteens in sections of the city. 

VII. Laundry. — 1. A special collection and distribution system may 
be essential both for homes and institutions. 

2. It may be necessary to take over a public laundry with compensa- 
tion, or a private non-medical institution laundry. 

Vm. Provision for Fatalities. — 1. Death reporting should be prompt 
(twenty-four hours) and a record kept so as to insure prompt disposal 
of bodies. 

The number of graves required should be estimated and labor 
released from public works or secured through other channels (possibly 
military) for digging. Possibly temporary trench interment may be 
necessary. 

IX. Education, Instruction and Publicity. — Literature and special 
instructions will be necessary on many phases, including the following : 

1. Instructions to physicians as to reporting, facilities available, 
district arrangements, etc. 

2. Advice to physicians regarding treatment standards and 
suggestions. 

3. Instructions for families, to be distributed by nurses, physicians, 
social workers, druggists, etc., covering the problems of care during the 
physician's absence. 

4. Instructions to the public as to where aid may be secured, to be 
printed in various languages, and distributed by druggists, displayed 
in street cars, used in the press, etc. 

5. Instructions for families on "What to do until the doctor comes." 

6. Instructions to physicians, factory managers, school superin- 
tendents, etc., urging the necessity for immediate home and bed treat- 
ment at the first sign of respiratory disease. 

7. Popular literature on the essentials of adequate care, the danger 
of returning to work too soon, etc. Popular press space is worth paying 
for, if it cannot be secured otherwise. 

8. Popular publicity as to legitimate medical, nursing, undertaker, 
drug, and other charges, to prevent profiteering. 

X. Miscellaneous. — 1. The cooperation of pharmaceutical agencies 
should be secured to insure an adequate supply of drugs and druggists. 

2. Influenza victims and their families should have "first call" on 
fuel deliveries. 

3. While follow-up procedures are not legitimately a factor in the 
epidemic situation, their consideration is essential to an adequate 
meeting of the entire problem. This means adequate provision for 



S4 PREY EXT ION OF INDIVIDUAL INFECTIOUS DISEASES 

medical examination and nursing care, relief measures, industrial 
employment problems; the follow up of special sequelae such as cardiac 
affections, tuberculosis, etc. 

4. It is finally suggested that Health Department draw up a program 
based on the above outline, holding it in reserve for future use, if not 
immediately needed, and modifying the proposal to fit the size and 
other characteristics of the particular community. 

The Bacteriology of the 1918 Epidemic of So-called Influenza. — 
The epidemic disease known as influenza is believed to be due to an 
undetermined organism which causes an infection that lowers the 
resistance of the body as a whole, and of the respiratory organs in 
particular. This allows the invasion of other pathogenic micro- 
organisms. The most important complicating infections are due to 
the influenza bacilli, different strains of pneumococci and different 
varieties of streptococci. Some careful observers regard certain of 
these organisms as the primary cause. 

In each case, one or several of these microorganisms may be present. 
In different portions of the country the dominating variety of organism 
has been found to differ. 

Vaccines. — i\ssuming that the cause of the epidemic is an unknown 
virus, it does not seem possible at present to prevent the primary dis- 
ease by vaccination with known organisms. Against the secondary 
infections, there would seem to be a theoretical basfe for the use of 
vaccines, and especially for the use of vaccines prepared from organ- 
isms responsible for complications which may differ in various localities 
at various times. This variable bacterial flora may militate against 
the practical application of vaccination on a large scale, because it 
would seem to require frequently repeated vaccinations with the flora 
that may be met with. It is impossible at present to evaluate the 
reports from the use of these vaccines adjusted to meet local condi- 
tions. More data obtained under carefully controlled conditions are 
needed. 

Stock vaccines made from the influenza bacillus alone or from other 
bacteria, such as the fixed types of the pneumococci, have been used to 
considerable extent. The injections of stock vaccines have seemed to 
mitigate to some degree some outbreaks of influenza and also the severity 
of the complicating infections; but in those instances in which the results 
of the use of vaccine have been controlled, no appreciable results have 
been obtained. The fact that the vaccine is usually employed after the 
epidemic has broken out and is perhaps on a decline, and the fact that an 
unknown number of people have been exposed, make it very difficult 
to draw conclusions as to its efficacy. 

Recommendations. — Your committee recommends that until such 
time as the efficacy, or the lack of efficacy, of prophylactic vaccination 
against influenza is established, vaccine if used, should be employed 
in a controlled manner, under conditions that will allow a fair compari- 
son of the number of cases and of deaths among the vaccinated and 
non-vaccinated groups. Particular attention should be directed to 



PNEUMONIA 85 

securing data as to the period in the epidemic at which vaccinated and 
non- vaccinated persons developed the disease. 

Your committee is of the opinion that the indiscriminate use of stock 
vaccines against influenza and influenza and pneumonia cannot be 
recommended. 

Nothing in these recommendations should be interpreted as dis- 
couraging the use of a pneumococcus stock vaccine against lobar 
pneumonia. 

This epidemic emphasizes the importance of properly equipped 
laboratories. 

PNEUMONIA (ACUTE LOBAR). 

An acute infectious disease characterized by inflammation of the 
lungs and constitutional disturbance of varying intensely, in which 
the fever usually terminates abruptly by crisis. Secondary infectious 
processes and complications are frequent. 

Pneumonia is one of the most prevalent and fatal of all acute diseases, 
rivalling and sometimes exceeding tuberculosis as a cause of death. 
It is most fatal in young adults and old persons, but no age or sex is 
exempt. The disease is apparently not decreasing in this country. 
Among the factors favoring the spread of the infection are over- 
crowding, and other influences of modern civilization which tend to 
diminish the vital resistance of the individual. Possibly more persons 
are now saved from the acute infections of childhood and early youth, 
moreover, to become later victims of pneumonia. One attack confers 
no immunity. This is probably due to the fact that lobar pneumonia 
may be due to a number of varieties of pneumococci, each one of which 
is affected by different antibodies. A case recovering from type I is 
probably more or less immune for some months at least to type I 
organisms, but such a case is not immune to type II, III or IV. 

Since the influenza epidemic lobar pneumonias have much more 
frequently than heretofore been due to type IV organisms. 

The disease has occurred in epidemic form, from time to time, in all 
parts of the world. Indeed, it may be properly considered to be pan- 
demic. 

Infectious Agent. — The infectious agent includes various pathogenic 
bacteria commonly found in the nose, throat and mouth, such as the 
pneumococcus, the bacillus of Friedlander, the influenza bacillus, etc. 

Four groups or strains of pneumococci are now known to be the usual 
cause of lobar pneumonia, viz., I, II, III and IV. The first three groups 
cause in ordinary times about 80 per cent, of all cases and occur in 
healthy persons most often in the mouths of convalescents from the 
disease or of those in direct contact with cases. 

Source of Infection. — The source of infection is the discharges from 
the mouth and nose of apparently healthy carriers as well as recog- 
nized infected individuals, and articles freshly soiled with such dis- 
charges. 



S6 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

Modes of Transmission. — The mode of transmission is by direct con- 
tact with an infected parson, or with articles freshly soiled with the 
discharges from the nose or throat of, and possibly from infected dust 
of rooms occupied by, infected persons. 

Incubation Period. — The incubation period is difficult to estimate, as 
the lobar pneumonia may occur in a carrier months after infection, if 
resistance is lowered. In an outbreak it is usually two to three 
days. 

The period of eommnnic ability is unknown; presumably until the 
mouth and nasal discharges no longer carry the infectious organisms 
in an abundant amount or in a virulent form/ 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the Disease. — Recognition of the disease by its 
clinical symptoms. The specific infecting agents may be determined 
by serological (agglutination) and bacteriological tests early in the 
course of the disease. 

2. Isolation. — Isolation of the patient during the clinical course of the 
disease. 

3. Immunization. — The results obtained in the mines of South 
Africa and in some of the army camps in Europe and America give 
some hope of a successful immunization against types I, II, and III. 
The U. S. P. S. is now carrying on extensive investigation in which 
every other inmate of a number of large institutions have been given 
some 5 billions of each of the three fixed types. 

4. Quarantine. — None. 

5. Concurrent disinfection of the discharges from the nose and throat 
of the patient. 

6. Terminal Disinfection. — Thorough cleansing, airing and sunning. 
II. General Measures. — In institutions and camps, when practicable, 

people in large numbers should not be congregated closely within doors. 

The general resistance of the individual should be conserved by good 
feeding, fresh air, temperance in the use of alcoholic beverages, and 
other hygienic measures. 

As carriers no doubt play an important part in spreading the infec- 
tion, the education of the public concerning spitting, sneezing and 
coughing, etc., and the peril of the common drinking cup and roller 
towel and of placing unnecessary things in the mouth, should be 
actively continued. 

BRONCHOPNEUMONIA. 

The preventive measures are exactly the same as in lobar pneumonia 
except for the fact that the causal microorganisms are still more varied. 
Not only different varieties of pneumococci are frequently met with, 
but also streptococci and influenza bacilli. This makes the possi- 
bility of devising an effective vaccine almost hopeless. 



Trachoma 87 

acute infectious conjunctivitis (not including 

TRACHOMA). 

This title is intended to replace the terms gonorrheal ophthalmia, 
ophthalmia neonatorum, babies' sore eyes, and other infectious eye 
troubles. 

Infectious Agent. — The infectious agents are the gonococcus or some 
member .of a group of pyogenic organisms including the hemoglobinic 
bacilli. 

Source of Infection. — The source of infection is the discharges from 
the conjunctiva?, or genital mucous membranes of infected persons, 
or with articles soiled by discharges. 

Mode of Transmission. — The modes of transmission are by contact 
with an infected person or with articles freshly soiled with discharges 
of such person. 

Incubation Period. — The incubation period is irregular, but usually 
thirty-six to forty-eight hours. 

Period of Communicability. — The period of communicability is during 
the course of the disease and until the discharges from the infected 
mucous membranes have ceased. 

Methods of Control. — 1. Concurrent disinfection of the conjunctival 
discharges and articles soiled therewith. 

General Measures. — 1. Enforcement of regulations forbidding the 
use of common towels and toilet articles. Education as to personal 
cleanliness. 

2. The use of a solution of silver nitrate in the eye of the newborn 
(Crede's method). 

TRACHOMA. 

Trachoma (Granular ophthalmia) is the name given to an infectious 
process in the eye, characterized by sbwly progressive changes in the 
conjunctiva and subconjunctival tissue, threatening the integrity of 
the eyesight. A number of observers doubt the clinical entity of this 
process. 

So serious, however, are the results of chronic inflammation of the 
membranes of the eyelids, that all immigrants arriving in the United 
States have their eyelids everted and conjunctivas examined for evi- 
dence of such an infection; and when found to be infected such aliens are 
deported, a penalty of $100 being exacted from the steamship that 
brings them in. For this reason, and because of improved sanitary 
surroundings in this country, trachomatous inflammations are less 
common here than they used to be. Such inflammations thrive best 
in unsanitary surroundings, and prevail more or less in the poorer 
sections of all large cities. When once well established permanent 
cures are doubtful. 

Infectious Agents. — The infectious agent has not been definitely 
determined, but the chief agents are thought to be the hemoglobinic 
bacilli including the so-called "Koch- Weeks" bacillus. 



88 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

Source of Infection. — The source of infection is the secretions and 
purulent discharges from the conjunctivae and adnexed mucous mem- 
branes of the infected persons. 

Mode of Transmission. — The mode of transmission is by direct con- 
tact with infected persons and indirectly by contact with articles 
freshly soiled with the infectious discharges of such persons. 

Incubation Period. — The incubation period is undetermined. 

Period of Communicability. — The period of communicability is during 
the persistence of lesions of the conjunctivas and of the adnexed mucous 
membranes or of discharges from such persons. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the Disease. — Recognition of the disease is by the 
clinical symptoms, assisted by bacteriological examination of the 
conjunctival secretions and lesions. 

2. Isolation. — Exclusion of the patient from general school classes, 
unless the dangers of contact can be eliminated. 

3. Immunization. — None. 

4. Concurrent disinfection of discharges and articles soiled therewith. 
II. General Measures. — 1. Search for Cases. — Search for cases by 

examination of school children, of immigrants and among the families 
and associates of recognized cases; and in addition, search for acute 
secreting diseases of the conjunctiva and adnexed mucous membranes 
both among school children and in their families, and treatment of 
such cases until cured. 

2. Elimination. — Elimination of common towels and toilet articles 
from public places. 

3. Education of the Public. — Education of the public in the principles 
of personal cleanliness and the necessity of avoiding direct or indirect 
transference of body discharges. 

4. Control of Public Dispensaries. — Control of public dispensaries 
where communicable eye diseases are treated. 

TUBERCULOSIS. 

Tuberculosis is one of the most widespread and fatal of diseases. 
It is the cause of death of about 9 per cent, of those dying from all 
causes in this country. It is conservatively estimated that more than 
160,000 persons in the United States die each year of tuberculosis 
and most of these in the period of life of greatest usefulness, that is, 
between the ages of fifteen and forty-five years. Not only does this 
disease consume the vital forces of the individual, disabling him for 
several years, perhaps, previous to death, but it destroys for the most 
part, the material prosperity of the family of the person it attacks. 
The money cost of tuberculosis, therefore, including capitalized earning 
power lost by death, has been estimated to exceed a billion dollars 
annually, two-fifths of which falls on others than the consumptive. 

Only gradually have we learned to appreciate the true proportions 
of this apparently uninfected community that has been attacked. 

According to the evidence of postmortem findings by various 



TUBERCULOSIS 89 

pathologists, a very large number of the bodies examined of persons 
who died of other diseases than tuberculosis show scars of old tuber- 
culous processes, in some places as many as 90 per cent. The majority of 
all persons more than a few years of age give the von Pirquet cutaneous 
reaction for tuberculosis. This has been tried in such multitudes of 
cases and under such varied conditions that we cannot doubt that 
nearly everone in civilized communities has at sometime slight lesions 
and that many have this latent infection at all times. 

There are several types of the tubercle bacillus causing the disease, 
of which the human and bovine types are the most important. These 
two varieties resemble each other very closely, the essential difference 
between them being that the human type is pathogenic for man but 
has little effect on cattle, rabbits, monkeys and other animals (except 
young guinea-pigs, which are very susceptible to human tuberculosis) ; 
while the bovine type is pathogenic for almost all mammalian animals. 
It is also pathogenic for man, but less so than the human bacillus. 
The widespread existence of the disease in cattle, from which we 
derive nearly all the milk, renders the bovine bacilli an important 
etiological factor in connection with tuberculosis in children. 

Xo age, sex or race is immune from the disease. The Indian and 
the Negro races of this continent are particularly susceptible. Tuber- 
culosis exists in all countries, but it is most prevalent wherever the 
population is crowded together. Although caused specifically by the 
tubercle bacillus, such conditions as are brought about by poverty, 
poor food, bad housing, overwork, worry, intemperance, etc., act as 
contributing causes in the production of the disease; while among the 
well-to-do and prosperous who can afford to buy good food, rest and 
recreation, and life in the open, these more wholesome conditions 
increase the vital resistance and enable them to avoid contact with 
the infection. 

A close study of tuberculosis indicates that the number of cases and 
deaths per 100,000 of the population began to lessen in those countries 
in which prosperity of the industrial workers improved even before 
the discovery of the tubercle bacillus. If nearly every one of us 
becomes infected at some time and yet less than one-tenth develop 
serious tuberculosis then it is certain that disease depends not so much 
upon infection but upon some other factors, especially such as show 
hunger and other infections which lessen resistance. How frequently 
following overwork, a cold, personal dissipation or childbirth a latent 
focus flares up. 

As Kraus has stated, anything that leads to an amelioration of the 
general habits and conditions of life of masses of people will work 
toward a subsidence of tuberculosis. 

Infection. — Infection in tuberculosis takes place usually through 
the respiratory tract or the digestive tract, including the pharynx and 
tonsils; more rarely through wounds of the skin. It is produced 
chiefly by the direct transmission of tubercle bacilli to the mouth 
through soiled hands, lips, handkerchiefs, food (milk, etc.), or by the 
inhalation of fine particles of mucus thrown off by coughing or loud 
speaking, or of tuberculous dust contaminated by sputum or feces. 



90 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

When the skin or mucous membranes are superficially infected 
through wounds there may develop lupus, ulceration, or a nodular 
growth. The latter two forms of infection are apt after an interval to 
cause the involvement of the nearest lymphatic nodes. 

The lungs are the most frequent location of clinically recognizable 
tuberculous inflammation. Most of the inhaled bacilli are caught 
upon the nasal or pharyngeal mucous membranes, a few of these may 
be caught in the tonsil or crypts or elsewhere but the great majority 
are swallowed. Some of these are destroyed, some pass with the feces 
and the remainder are absorbed. The last may be destroyed or cause 
the infection of the nearest lymph gland or pass along and enter the 
blood and be carried to a bronchial lymph node or elsewhere. In the 
infant blood infection is apt to be followed by generalized tubercu- 
losis while in the adult this is apt to be localized. Only a small per- 
centage can find their way directly to the trachea, and still less to 
the larger and smaller bronchioles. 

Dried and Moist Sputum. — A common mode of infection is by means 
of tuberculous sputum, which, being coughed up by consumptives, is 
either disseminated as a fine spray (droplet infection) and so inhaled, 
or, carelessly expectorated, dries and, broken up by tramping over it, 
sweeping, etc., distributes numerous virulent bacilli in the dust (dust 
infection). As long as the sputum remains moist there is no danger 
of dust infection; it is when it becomes dry, as on handkerchiefs, bed- 
clothes, or the floor, etc., that the dust is a source of danger. 

A great number of the expectorated and dried tubercle bacilli 
undoubtedly die, especially when exposed to the action of direct sun- 
light, but when it is considered that as many as 5 billion virulent 
bacilli may be expectorated by a single individual in twenty-four hours, 
it is evident that even a much smaller proportion than are known 
do stay alive will suffice in the immediate vicinity of consumptives to 
communicate the organism unless precautions are taken to prevent it. 
The danger is greatest, of course, in the close neighborhood of tubercu- 
lous patients who expectorate profusely and indiscriminately, that is, 
without taking necessary means of preventing infection. There is 
much less danger of infection in the streets, for instance, where the 
bacilli have become diluted. In rooms the sputum is not only protected 
from the direct sunlight, but it is constantly broken up and blown about 
by the walking, etc. In crowded streets on windy days it is reasonable 
to suppose that infected dust must sometimes be in the air unless the 
expectoration of consumptives is controlled. 

On the whole, it may be said that the danger of infection of the 
adult from contact with the tuberculous is not so great as it is 
considered by many. Those who are most liable to infection from 
this source are especially infants and young children who have not 
become partially immunized through earlier slight infections. In 
this connection, also, attention may be drawn to the fact that 
rooms which have been recently occupied by consumptives are not 
infrequently the means of producing infection from the deposi- 
tion of tuberculous dust on furniture, walls, floors, etc. The danger 



TUBERCULOSIS 91 

is not apt to last beyond three months, although a few live bacilli 
ma}' be detected in sheltered places for a year. Fliigge has shown 
that in coughing, sneezing, etc., very fine particles of throat secretion 
containing bacilli are thrown out and carried by air currents many 
feet from the patient and remain suspended in the air for a considerable 
time. To encourage us, however, we now have a mass of facts which 
go to prove that when the sputum is carefully looked after there is 
very little danger of infecting others except by close personal contact. 

Ingestion infection. — Milk serves as a conveyor of infection, whether 
it be the milk of nursing mothers or the milk of tuberculous cows. In 
this case the evidence of infection is usually shown in the mesenteric 
and cervical lymph nodes, or generalized tuberculosis may be caused, 
while the intestinal walls are frequently not affected. Bacilli accom- 
panied by fat pass readily through the intestinal mucous membrane 
or that of the tonsils and pharynx. 

Formerly it was thought that in order to produce infection by milk 
there must be a local tuberculosis affection of the udder. But it is 
now known that while this is usually so, nevertheless tubercle bacilli 
may be found in the milk in small numbers, when adjacent tissue is 
infected, and when there is apparently no udder disease. It has also 
been shown that the feces are a very dangerous factor in the dissemina- 
tion of tubercle bacilli from cows. Butter, too, may contain tubercle 
bacilli in considerable numbers, as the butter is stored the bacilli 
gradually die. When we consider the prevalence of tuberculosis 
among cows we can readily realize that even if the bovine bacillus is 
not very pathogenic for man, there is great danger to children who are 
constantly exposed to this source of infection. The milk from cows 
suffering from udder tuberculosis usually contains several hundred 
bacilli per c.c, but may contain many million. The mixed milk from 
a herd, therefore, tending to dilute the milk of cows excreting tubercle 
bacilli, may be badly infected from one cow, especially if this cow has 
udder disease. Bacilli have been found in from 10 to 30 per cent, of 
samples of city milk examined. 

About 10 per cent, of the cattle slaughtered in various countries 
have been found to be tuberculous. But the danger of infection from 
eating the meat of tuberculous cattle is very slight. This is owing to 
the fact that the meat is usually cooked thoroughly before eating, and 
because the muscular tissues are seldom involved. 

Bovine Infection in Man. — Numerous investigations made on this 
point have abundantly shown that such infection does take place. 
As the result of a large series of cases reported by ourselves and others, 
it has been shown: (1) That children are especially infected, and 
usually the point of entry is the alimentary tract; (2) that cervical 
adenitis and abdominal tuberculosis are the most frequent types of 
infection; (3) that generalized tuberculosis due to bovine infection is 
less frequent; (4) that bone and joint tuberculosis is most commonly 
of the human type; (5) that the meninges are less commonly affected 
by the bovine than the human type; (6) that the infection of adults 
is very infrequent; and (7) that though cases of pulmonary tuberculosis 



92 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

due to the bovine type of bacillus have been reported, such cases are 
rare. 

A careful study of all the factors lead us to estimate that about 10 
per cent, of all deaths caused by tuberculosis in children under five 
years of age is due to bovine infection when the milk is not pasteur- 
ized. The following two tables summarize the results: 

COMBINED TABULATION, CASES REPORTED AND OWN SERIES OF CASES. 



Diagnosis. 


Adults sixteen 
years and over. 


Children five to 
sixteen years. 


Children under 
five years. 




Human. 


Bovine. 


Human. 


Bovine. 


Human. 


Bovine. 


Pulmonary tuberculosis .... 

Tuberculous adenitis, axillary or 
inguinal ........ 

Tuberculous adenitis, cervical . 
Abdominal tuberculosis .... 

Generalized tuberculosis, alimentary 

origin 

Generalized tuberculosis .... 
Generalized tuberculosis, including 

meninges, alimentary origin . 
Generalized tuberculosis, including 

meninges 

Tubercular meningitis .... 
Tuberculosis of bones and joints 
Genito-urinary tuberculosis . 

Tuberculosis of skin 

Miscellaneous cases: 

Tuberculosis of tonsils . 
Tuberculosis of mouth and cer- 
vical nodes 

Tuberculous sinus or abscesses . 
Sepsis, latent bacilli .... 


568 

2 
22 
15 

6 

28 

4 

18 
11 

2 


K?) 

1 
3 

1 
1 


11 

4 
33 

7 

2 
4 

1 

7 

2 

26 

1 

1 


20 

7 

3 


12 

2 

15 

6 

13 

28 

3 

45 
14 
21 

1 


20 
13 

10 
5 

8 

1 
2 


Totals 


677 


9 


99 


33 


161 


59 



Mixed or double infection, 4 cases. 
Total cases, 1042. 



We have arranged the cases included in the tables so as to show the 
percentage of bovine infection according to the main types of disease 
and the age of the individuals infected. These are as follows: 



PERCENTAGE OF BOVINE INFECTION. 1 



Diagnosis. 


Adults sixteen 


Children five 


Children under 


years and over. 


to sixteen years. 


five years. 


Pulmonary tuberculosis .... 


2 per cent. 


per cent. 


per cent. 


Tuberculous adenitis, cervical 


4 


37 


57 


Abdominal tuberculosis .... 


16 


50 


68 


Generalized tuberculosis .... 


3 


40 


26 


Tubercular meningitis (with or with- 








out generalized lesions) .... 








15 


Tuberculosis of bones and joints . 


5 


3 






1 Exclusive of the cases of double infections. In considering the pulmonary cases it 
must be remembered, however, that bovine tubercle bacilli have been isolated from the 
lung in cases of generalized tuberculosis in children. 

2 If one doubtful case admitted, 0.2 per cent. 



TUBERCULOSIS 93 

Susceptibility. — It was formerly believed that in demonstrating that 
tuberculosis was caused by a specific bacillus its occurrence was 
adequately explained; but it is now known that there is another 
important factor in the production of this and other infectious diseases, 
viz.: individual susceptibility. At first the inherited susceptibility 
was thought to be more important than the acquired, but now much 
that was attributed to the former is known to be explained by the 
fact of living in an infected area. The acquired susceptibility may 
arise from faulty physical development or from depression, sickness, 
child-bearing, overwork, strain of any kind, excessive use of alcohol, 
etc., which lowers the resistance of the individual. Unquestionably 
great differences exist in different persons in the intensity of the 
tuberculous processes. That this does not depend upon a difference 
of virulence of the infection is evident from the fact that individuals 
contracting tuberculosis from the same source are attacked with dif- 
ferent severity, and that there is, as a rule, no great difference in degree 
of virulence for animals in the tubercle bacilli obtained from different 
sources. Clinical experience teaches, likewise, that good hygienic 
conditions, pure air, good food, freedom from care, etc., increases 
immunity to tuberculosis. Animal experiments have shown that not 
only are there differences of susceptibility in various species, but also 
in individual susceptibility in the same species and that this can be 
lowered by subjecting the individuals under test to strains. The 
doctrine of individual susceptibility is therefore seen to be founded in 
fact, although the reasons for it are as yet only partially understood. 

Immunity. — The great majority of mankind has, in varying degree, 
a natural immunity against tuberculosis. In many individuals, 
however, this immunity is only relative and is maintained only as long 
as the health is kept at a high standard or the exposure to infection is 
not too intense or prolonged. 

Most of us become infected during the early years of life, and a large 
part of such infections remain latent. As long as these latent lesions 
exist and the general resistance is good, a relative immunity to reinfec- 
tion persists. Should, however, this immunity be lowered by some 
factor as an infectious disease, exposure, fatigue, etc., dissemination 
occurs, which then progresses, or in turn with recovery of the general 
bodily resistance, regresses and the immunity again rises and protec- 
tion is reestablished. 

We may therefore conclude that childhood is the most frequent 
time of infection, that the disease in later life is usually an auto-infec- 
tion from the lesions so acquired, and that most adults have little 
reason to fear contact infection. 

Nevertheless, the precautions now taken should not be relaxed for 
there are some persons who, because of the complete healing of a pre- 
viously existed lesion or having escaped infection, are susceptible. 
There is reason to believe, however, that those who have lost their 
immunity through the complete healing of their lesions are on the 
average more protected than those who have escaped infection. 



94 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

Should they become reinfected they would probably, reestablish their 
immunity more promptly and thus limit or destroy the bacilli which 
found entry. 

As in other infectious diseases many attempts have been made to 
produce an artificial immunity against tuberculosis, but so far the 
results have been disappointing. There is little at first glance in the 
clinical history of tuberculosis to show that acquired immunity occurs, 
since relapse is the rule. For this reason, the production of an artificial 
immunity against tuberculosis has been looked upon by many as a 
result possibly incapable of achievement. The careful study of tuber- 
culosis seems, however, to indicate an attempt on the part of Nature 
for the production of an acquired immunity. The inoculation of living 
cultures or of toxins and dead bacilli (as in Koch's tuberculin and other 
preparations) is an effort to imitate Nature's method of immunization. 

Tuberculin has not proved to be a cure for tuberculosis. It does 
promote healing, however, and relapses are less frequent after its use; 
but it should be used as an addition to, not as a substitute for, the 
recognized methods of treatment, and it should be employed only by 
those who have a thorough understanding of its possibilities for good, 
and, unfortunately also, in inexperienced hands for harm. 

The Institutional Care of the Tuberculous. — If it is impossible to reduce 
the spreaders of tubercle bacilli to an extent that will prevent practi- 
cally every one receiving frequently tubercle bacilli and at some time 
becoming infected can we consider the sanatorium as now developed 
or its future possibilities as a hopeful measure of eliminating tuber- 
culosis? 

This does not seem plausible. The great value of institutional care 
is to restore to complete or partial health those who have developed 
tuberculosis. Unquestionably the education and temporary removal 
of so many will prevent a considerable number of infants and young 
children and some adults from becoming infected at inopportune 
times. This removal of infection may amount to more than we now 
think. The unusual prevalence of clinical tuberculosis among children 
in tuberculous families indicates that personal contact with open cases 
is much more dangerous than the accidental infection from contact at 
play and school. 

Summary. — Source of Infection. — The source of infection is the 
specific organism present in the discharges, or articles freshly soiled 
with the discharges from any open tuberculous lesions, the most 
mportant discharge being sputum. Of less importance are discharges 
from the intestinal and genito-urinary tracts or from lesions of the 
lymphatic glands, bone and skin. 

Mode of Transmission. — The mode of transmission is by direct or 
indirect contact with an infected person by coughing, sneezing, or other 
droplet infection, kissing, common use of unsterilized food utensils, 
pipes, toys, etc., and possibly by contaminated flies and dust, 



LEPROSY 95 

Incubation Period. — The incubation period is variable and dependent 
upon the type of the disease. 

Period of Communicability. — The period of communicability exists 
as long as the specific organism is eliminated by the host. It commences 
when a lesion becomes an open one, and continues until it heals or 
death occurs. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the Disease. — Recognition of the disease by the 
clinical symptoms and by thorough physical examination,, confirmed 
by bacteriological examination and by serological tests. 

2. Isolation. — Isolation of such "open" cases as do not observe the 
precautions necessary to prevent the spread of the disease. 

3. Immunization. — None efficient. 

4. Quarantine. — None. 

5. Concurrent Disinfection. — Concurrent disinfection of sputum and 
articles soiled with it. Particular attention should be paid to prompt 
disposal or disinfection of the sputum itself, of handkerchiefs, cloths, 
or paper soiled therewith, and of eating utensils used by the patient. 

6. Terminal Disinfection. — Renovation. 

II. General Measures. — 1. Education of the Public. — Education of the 
public in regard to the dangers of tuberculosis and the methods of 
contact, w T ith especial stress upon the danger of exposure and infection 
in early childhood. 

2. Provision of Dispensaries. — Provision of dispensaries and visiting- 
nurse service for the discovery of early cases and the supervision of 
home cases. 

3. Provision of Hospitals.- — Provision of hospitals for isolation of 
advanced cases and sanatoria for the treatment of early cases. 

4. Provision of Open-air Schools. — Provision of open-air schools and 
prevention for pre-tuberculous children. 

5. Improvement of housing conditions of the poor. 

6. Ventilation and elimination of dust in industrial establishments 
and places of public assembly. 

7. Improvement of habits of personal hygiene and betterment of 
general living conditions. 

8. Separation at birth of babies from tuberculous mothers. 
Pasteurization to render the general milk supply safe. 



LEPROSY. 

Leprosy is one of the oldest of known diseases and it still prevails 
widely in hot countries, such as India, China, Japan and South Africa. 
In Europe, where it prevailed in epidemic form in the middle ages, 
it has become almost unknown except in Norway, Sweden, Finland, 
Russia, Turkey, Spain, Italy and Greece. There are a large number 
of cases in the Philippine Islands, the Hawaiian Islands and some in 
Guam and Porto Rico, On this continent leprosy exists in the Gulf 



96 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

States, among the orientals on the Pacific Coast, and extensively in 
Mexico. 

The disease attacks all classes and persons of all ages. Males are 
more frequently affected than females, apparently. It is probably 
always communicated directly from the sick to the well, but close, 
intimate and prolonged association with a leprosy patient seems neces- 
sary to contract the infection. Not only is the disease not nearly so 
contagious as was popularly supposed but the conditions met with in 
civilized nations and amid modern sanitary surroundings are unfavor- 
able to its spread. 

In many respects leprosy is similar to tuberculosis. This relation 
between the two diseases is rendered still more remarkable by the fact 
that leprosy reacts, both locally and generally, to an infection of tuber- 
culin in the same manner as tuberculosis, but to a somewhat less 
extent. Like tuberculosis, leprosy is not always fatal but may be 
treated in the same way with possibility of curtailment. 

Infectious Agent. — The infectious agent is the bacillus leprae, found 
in all the diseased parts and usually in large numbers, especially in 
the tubercles on the skin, in the conjunctiva and cornea, the mucous 
membranes of the mouth, gums and larynx, and in the intestinal 
processes of the nerves, testicle and spleen, liver and kidneys. 

Source of Infection. — The source of infection is the discharge from 
lesions. 

Mode of Transmission. — The mode of transmission is by close, intimate 
and prolonged contact with infected individuals. Flies and other 
insects may possibly act as mechanical carriers. 

Incubation Period. — The incubation period is prolonged and undeter- 
mined. 

The Period of Communic ability .^Infectivity exists throughout the 
duration of the disease, but under ordinary circumstances this disease 
is but slightly communicable. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the Disease. — Recognition of the disease by the 
clinical symptoms, confirmed by bacteriological examination. 

2. Isolation. — Isolation for life in national leprosorium when this is 
possible. 

3. Immunization. — None. 

4. Quarantine. — None. 

5. Concurrent disinfection of discharges and articles soiled with them. 

6. Terminal Disinfection. — Thorough cleansing of living premises 
of the patient. 

II. General Measures. — 1. Lack of information as to the determining 
factors in the spread and communication of the disease makes any 
but general advice in matters of personal hygiene of no value. 

2. As a temporary expedient, lepers may be properly cared for in 
local hospitals, or if conditions of the patient and his environment 
warrant, he may be allowed to remain on his own premises under 
suitable regulations. 



CEREBROSPINAL MENINGITIS 97 



CEREBROSPINAL MENINGITIS. 



This is a specific infectious disease, occurring sporadically and in 
epidemics, characterized by inflammation of the cerebrospinal meninges 
and a clinical course of great irregularity. 

Infective Agent. — The infective agent of epidemic meningitis is the 
diplococcus intracellularis meningitidis (meningococcus). But not 
all cases of meningitis are caused by the meningococcus. Sporadic 
cases may be due to the pneumococcus, streptococcus ; bacillus of 
influenza, the colon bacillus, the typhoid bacillus, the bacillus of 
bubonic plague and of glanders. The gonococcus may also cause men- 
ingitis as a secondary infection. The epidemic form of cerebrospinal 
meningitis is probably always due to the meningococcus. 

Incidence. — The epidemics have occurred most frequently in winter 
and spring, thus corresponding to the seasonal prevalence of pneu- 
monia and influenza, and other infectious diseases spread by discharges 
of the respiratory tract, but differing in this respect from infantile 
paralysis, the epidemics of which have occurred most frequently in the 
summer months (July to September). 

Neither soil nor locality has any special influence. Overcrowding 
and concentration of individuals, as in living quarters and public places 
in cities, and in large barracks, camps or on shipboard, seem to favor 
the incidence of the disease. 

Children and young adults are most susceptible, though the sus- 
ceptibility has differed in different epidemics; it also varies in the 
individual. Males and females are equally attacked. Certain epi- 
demics have been most prevalent in country districts. One attack 
does not confer lasting immunity. 

Source of Infection. — The source of infection is the discharge from 
the nose and mouth of infected persons. Clinically recovered cases, 
and healthy persons who have never had the disease but have been in 
contact with cases of the disease or other carriers, act as carriers 
and are commonly found, especially during epidemics. Such healthy 
carriers are not uncommonly found independent of epidemic preva- 
lence of the disease. 

Mode of Transmission. — The mode of transmission is by direct con- 
tact with infected persons and carriers, and indirectly by contact with 
articles freshly soiled with the nasal and oral discharges of such persons. 

Incubation Period. — The incubation period is from two to ten days, 
commonly seven; occasionally for longer periods when a person is a 
carrier for a time before developing the disease. 

Period of Communic ability. — The period of communicability is during 
the course of the disease and until the specific organism is no longer 
present in the nasal and mouth discharges of the patient. The same 
applies to healthy carriers so far as affects persistence of infecting 
discharges. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the Disease. — Recognition of the disease by its 
7 



98 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

clinical symptoms, confirmed by the microscopic and bacteriological 
examination of the spinal fluid and by bacteriological examination of 
nasal and pharyngeal secretions. 

2. Isolation. — Isolation of infected persons and carriers until the 
nasopharynx is free from the infecting organism, or, at the earliest, 
until one week after the fever has subsided. 

3. Immunization. — Immunization may prove of value, although the 
use of vaccines for immunization is still in the experimental stage. 

4. Concurrent Disinfection.- — Concurrent disinfection of discharges 
from the nose and mouth and of articles soiled therewith. 

5. Terminal Disinfection. — Cleansing. 

n. General Measures. — General measures for the prevention of cerebro- 
spinal meningitis, though plainly indicated, are extremely difficult to 
carry out effectively. These consist of 

1. Search for Carriers. — Search for carriers among families and asso- 
ciates of recognized cases by bacteriological examination of the pos- 
terior nares of all contacts. Only a thoroughly trained technician can 
be trusted to isolate the meningococcus, and even such a one will 
frequently miss them when they are few in number. Cultures from the 
nasopharynx are most liable to reveal them. 

2. Education of the public as to personal cleanliness, washing of the 
body daily and of the hands in soap and water before eating, keeping 
hands and unclean articles away from mouth, nose, etc., avoiding the 
use of common or unclean eating drinking or toilet articles of any kind, 
avoiding direct exposure to the spray from the nose and mouths of 
people who cough or sneeze, etc., and the necessity of avoiding contact 
infection. 

3. Prevention of overcrowding, such as is common in living quarters, 
transportation conveyances, working places and places of public 
assembly in the civilian population, and in inadequately ventilated 
barracks, camps and ships among military units. 

Antimeningitis serum is useful in the treatment of the diseas?, but 
it is not practical as a preventive measure so far as it has been tested. 

POLIOMYELITIS (INFANTILE PARALYSIS). 

Poliomyelitis is an acute infectious disease, occurring sporadically 
and in epidemics, characterized by symptoms of a general infection, 
with the lesions most marked in the central nervous system. The 
clinical manifestations exhibit a widespread and scattered motor paral- 
ysis or weakening. 

Incidence. — Although poliomyelitis has in the last few years assumed 
a special importance because of its increasing prevalence, particularly 
in the United States, it has been known for many years in various parts 
of the world, especially in Scandinavian countries. 

Formerly it was looked upon as a rural disease, but most of the 
recent epidemics have occurred in cities, although not in the crowded 
parts of cities. Social conditions and sanitary surroundings apparently 



POLIOMYELITIS 99 

have no influence whatever on the incidence or spread of the infection. 
In New York City in 1907 there was an epidemic of over 2000 cases, 
and again in 1916 of nearly 9000 cases (the largest epidemic ever 
recorded and giving a case mortality of 26.9 per cent.). 

No age, sex or race is exempt, but the majority of cases occur among 
children under five years of age. Males appear to be more susceptible 
than females. One attack of the disease confers a high degree of 
immunity, but recurrent and second attacks have been reported. 

Infectious Agent. — This is constantly present in the brain and in the 
mucous membrane of the nose and pharynx, the mesenteric and inguinal 
glands, and in the intestinal secretions. 

Source of Infection. — The source of infection is the nose, throat and 
bowel discharges of infected persons or articles recently soiled therewith. 
Healthy carriers are supposed to be common. 

Mode of Transmission. — The mode of transmission is by direct con- 
tact with the infected person or with a carrier of the virus, or indirectly 
by contact with articles freshly soiled with the nose, throat or bowel 
discharges of such persons. 

Other modes of transmission have been suspected, as for instance 
certain flies and insects from the similarity of the disease to an insect 
bowel infection, dust, food, etc. ; but none of these theories have been 
corroborated by actual experience. 

Incubation Period. — The incubation period is from three to ten days, 
commonly six days. 

Period of Communicability. — The period of communicability is un- 
known; apparently not usually more than twenty-one days from the 
onset of the disease. 

Methods of Control. — These can be tentative only until the mode 
of transmission of the disease is more definitely known. 

1. The Infected Individual and his Environment.- — 1. Recognition of 
the Disease by its clinical symptoms, assisted by chemical and micro- 
scopical examination of the spinal fluid. 

2. Isolation of all recognized cases. 

3. Immunization. — None. 

4. Quarantine of exposed children of the household and of adults of 
the household whose vocation brings them into contact with children, 
or who are food handlers, for fourteen days from the last exposure to a 
recognized case. 

5. Concurrent Disinfection of nose, throat and bowel discharges and 
articles soiled therwith. 

6. Terminal Disinfection. — Cleansing. 

n. General Measures. — 1. Search for and examination of all sick 
children should be made as far as possible. 

2. All children with fever should be isolated pending diagnosis. 

3. Education in such technic of bedside nursing as will prevent the 
distribution of infectious discharges to others from cases isolated at 
home. 



100 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 



DIPHTHERIA. 

The lesions of diphtheria are caused by toxemia. The concentrated 
poison at the seat of the exudate causes intense local inflammation, 
while in the more severe cases the absorbed poison diffused throughout 
the body produces widespread cellular injury, giving rise to definite 
injury of the cells of the muscle, nerve and other tissues. 

The disease is endemic in the larger centers of population, and 
becomes most active in the late fall and winter months. While the 
seasonal prevalence is in the colder months, an epidemic when once 
established may occasionally run into the summer, regardless of the 
season. Damp dwellings favoring colds and sore-throats, as other 
depressing influences may predispose to the infection. There is no 
relation, except for the effect of bad smells and the toxic gas, however, 
between imperfect drains and sewer gas and the cause of diphtheria, 
as has been popularly supposed. Of the predisposing causative factors 
age is one of the most important. Infants under six months are rarely 
attacked, the majority of cases occurring between the beginning of the 
second and the tenth years. Adults are not infrequently affected. 

MORTALITY ACCORDING TO AGES FROM DIPHTHERIA IN CITIES AS 
EXEMPLIFIED IN NEW YORK CITY, 1891-1900 

Ages. Number. Per cent. 

Under six months 555 3 . 

6 months to 1 year 1,110 6.0 

1 to 2 years 4,263 23.0 

2to 3 " 3,817 21.2 

3 to 4 " 2,900 16.1 

4to 5 " 1,908 10.6 

Under 5 " 14,553 81.5 

5 to 10 " 3,052 17.0 

10 to 15 " . 241 1.3 

Over 15 years \ . . 35 0.2 

The immunity conferred by an attack of diphtheria varies in different 
individuals; it usually persists for some months or years. In most 
cases recovery is due to the development of bactericidal bodies rather 
than antitoxin. Cases which have not received antitoxin show a positive 
Schick test after recovery in about 75 per cent. When second and even 
third attacks are investigated they are usually found to be some other 
throat infection; that many persons enjoy a high degree of immunity, 
due to antitoxin or other antibodies in the blood, is shown by the fact 
that they may harbor virulent bacilli in their throats for a long time 
without contracting the disease. 

The individual susceptibility to diphtheria also varies greatly. The 
presence or absence of susceptibility to or immunity against the dis- 
ease in any individual may be readily determined by the Schick test, 
which tells whether antitoxin is present or absent in the blood of that 
individual. Those showing a negative test are immune. Those show- 
ing a positive test have no antitoxin immunity, but may have a 
bactericidal immunity. 



DIPHTHERIA 101 

Infecting Agent. — The infectious agent is the bacillus diphtheria 
(the Klebs-Loeffler bacillus). 

Source of Infection. — The source of infection is the discharges from 
diphtheritic lesions of the nose, throat, conjunctiva, vagina and wound 
surfaces; and secretions from the nose and throats of the bacillus 
carriers. 

Mode of Transmission. — The mode of transmission is directly by per- 
sonal contact, indirectly by articles freshly wet with discharges, or 
through infected milk or milk products. 

Incubation Period. — The incubation period is usually two to five 
days, occasionally longer if a healthy carrier stage precedes the develop- 
ment of clinical symptoms. 

Period of Communic ability. — The period of communicability is until 
the virulent bacilli have disappeared from the secretions and the 
lesions. The persistence of the bacilli after the lesions have healed is 
variable. In fully three-fourths of the cases they disappear within 
two weeks. 

Prevention. — Diphtheria, like other infections of the respiratory tract 
has shown an irregular increase during the past century. This was 
probably due to the increasing concentration of people in great cities 
with the accompanying added risk of infection from contact with 
carriers of diphtheria bacilli. These infected persons we now know 
to have been not only actual or recently recovered cases, but healthy 
people who had become carriers. The disease first appeared in coun- 
tries in the form of epidemics, but later remained more or less prevalent 
throughout years. 

With the discovery of the diphtheria bacillus and the use of diagnostic 
cultures, it seemed at first that this tendency to increase would be 
stopped and that a marked diminution would follow since it would be 
possible to carry out the more general and accurate isolation of the 
true cases of diphtheria whether mild or severe. New York City 
began the general employment of diagnostic cultures in the fall of 
1893. The city had had for the two previous years a steadily increas- 
ing number of cases. The results were disappointing. In spite of the 
general use of cultures for isolation and discharge the amount of 
diphtheria did not dimmish. The reasons for this soon became 
evident. These were partly dependent on the failure of cultures to 
always reveal bacilli in convalescent cases when only a few were 
present in the throat as in a crypt of the tonsils and partly on the great 
number of healthy persons who were carriers and who could not be 
cultured. It was soon discovered that not only the convalescent cases 
remained carriers for from a few days to many weeks, but that persons 
in contact with them frequently became carriers without developing 
the slightest disease and that those in turn infected others, who might 
themselves become carriers or true cases. The number of carriers 
was indicated in tests such as the following, a single swabbing of the 
tonsils revealed the presence of virulent bacilli in over 1 per cent, of 
1000 healthy school children examined. 



102 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

The technical difficulties which would be encountered in culturing 
a whole population and the disturbance of life that would follow the 
isolation of all healthy carriers made it impracticable to even attempt 
to clear masses of people from infection. In institutions, schools and 
families, however, attempts have frequently been made to detect and 
remove carriers. The results have sometimes been successful, but 
more often they have failed. The general outlook in 1899 was not 
encouraging. Just at the time this knowledge had been acquired the 
discovery of diphtheria antitoxin renewed hope for the ultimate 
conquest of the disease. The drop in deaths following its use was 
remarkable in every city and was always coincident with the introduc- 
tion of antitoxin and this improvement has not only been held during 
the twenty-four years of its use, but until recently this improvement 
has grown greater, so that there cannot be any doubt in any candid 
and enlightened mind of the cause. At the present time New York 
City instead of an average death-rate of about 150 per 100,000 in the 
decade before 1895 has one of about 22. The influence of antitoxin 
upon the mortality and morbidity due to diphtheria was twofold. 
If 1000 units were given at the time of exposure then antitoxin gave 
absolute protection in all persons for ten days and in most for three 
weeks. Each repetition of the injection gave an added period of safety 
of from seven days to one week. The short duration of the protection 
is due to the fact that the antitoxin was produced in a horse and as a 
horse product it is a foreign protein in man and it is therefore rather 
quickly eliminated. 

An interesting experiment was carried out some time ago which 
prettily demonstrated this. We possessed in addition to our regular 
product some diphtheria antitoxin produced in guinea-pigs and some 
in goats. We injected each of one series guinea-pigs with ten units of 
guinea-pig produced antitoxin, another series with ten units of horse 
antitoxin and a third series with ten units of goat antitoxin. At the 
end of two weeks examples of each series withstood two fatal doses of 
toxin. At the end of three weeks only examples of guinea-pigs from the 
lot receiving the guinea-pig antitoxin remained protected. This lot 
did not lose immunity till after six months. The second injection of 
the antitoxin is eliminated even more quickly. This is due probably 
to the development of antiferments to the horse antitoxin globulin. 
The use of antitoxin immunizing injection has been very effectual in 
infected families and institutions. The first trial in this country was 
most instructive. An institution caring for several hundreds of young 
children became infected with diphtheria. Each day one to six new 
cases appeared. The inmates were cultured again, but always some 
would escape detection or new cases would be infected during the 
period of the incubation of the cultures. When some weeks had 
elapsed Dr. Biggs brought over a considerable supply of antitoxin 
from Europe. It was determined to give every child 300 units of 
antitoxin. All the children received it the same day. The outbreak 
stopped absolutely. On the 12th day a doubtful case developed. A 



DIPHTHERIA 103 

second injection was given. No more cases occurred. I have never 
seen the use of an immunizing dose of antitoxin to fail for the period 
the antitoxin remains in the body. As over 50 per cent, of the cases of 
diphtheria occur in persons not known to have been exposed to cases, 
no amount of thoroughness of giving immunizing injections to those 
exposed could be expected to eliminate the greater proportion of cases 
now occurring in large centers of population. The use of immunizing 
injections must be supplemented therefore by its use in treatment. 

Those that die from diphtheria do so either from the direct toxin 
effects or from the injury caused by the invasion of other bacteria 
which have gained a foothold on account of the lowered resistance due 
to injury from the diphtheria poisons. The diphtheria antitoxin acts 
only on the toxin. It should be given therefore at the earliest possible 
moment and in sufficient amount. As a subcutaneous or intramuscular 
injection is slowly absorbed, it is necessary to give antitoxin intra- 
venously in serious cases. As it remains in the blood for a number 
of days one injection suffices. There is no harm in giving several 
provided that sufficient dose is given the first time. 

The use of antitoxin has little if any effect in freeing carriers from 
diphtheria bacilli. They remain imbedded in some crypt of the 
tonsils or other inaccessible place. Suitable antiseptics are for the 
same reason of little value. Irritating antiseptics do harm. Diph- 
theria antitoxin for the previously mentioned reasons has had more 
effect on the mortality from diphtheria than on its prevention. The 
number of cases in each 1000 of the population has not decreased over 
one-third. During the past few years there has been less and less im- 
provement. It is probable that with the help of the medical profession 
the people may be brought to report cases more promptly and to allow 
immunization more generally than they do now. If so a further slight 
improvement in mortality and morbidity may be obtained. There will 
nevertheless remain, unless all signs fail, a large number of cases and a 
considerable number of deaths unless we can produce in the susceptible 
portion of the population a durable immunity. 

The Schick Reaction and Its Practical Application. — The results of 
combined clinical and laboratory experience in testing the blood for 
antitoxin in cases of diphtheria and in persons in contact with diph- 
theria have shown that only those individuals contract diphtheria who 
have no antitoxin or only a minute amount in their blood and tissues. 
Schick, in 1913, published a description of a simple clinical test by 
which this can be accurately accomplished. The reaction depends on 
the local irritant action of minute quantities of diphtheria toxin when 
injected intracutaneously. If antitoxin is absent or present only in 
very small amounts, insufficient for protection from diphtheria, a 
positive reaction will appear in from twenty-four to forty-eight hours. 

The Positive Reaction. — A positive reaction is characterized by a 
circumscribed area of redness and slight skin infiltration which measures 
from 1 to 2 centimeters in diameter. It persists for five to fourteen 
days, and on fading, shows, as a rule, superficial scaling and a per- 



10-4 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

sistent brownish pigmentation. The amount of toxin injected, as 
advised by Schick, is ^V M. L. D. (minimum lethal dose) for the 
guinea-pig, in 0.1 e.c. of normal saline. We use 5V M. L. D. in 0.2 c.c. 
There is one advantage in Schick's dilution in that it permits consider- 
able deterioration of the toxin and still leaves it sufficiently strong to be 
effective. We are making comparative tests and may return to 
Schick's original dosage. It is desirable to give exactly 0.2 c.c. but 
even such variations as 0.1 c.c. and 0.3 c.c. give fairly consistent results 
— the area of redness being smaller when 0.1 c.c. is given and larger 
where 0.3 c.c. It is absolutely necessary to give it intracutaneously 
so that the toxin will remain in the dense tissue and have time to exert 
its irritant action. The slightly raised white area, at the point of 
injection, is infallible evidence of the delivery intracutaneously of the 
diluted toxin. 

The Pseudoreaction. — Shick noticed that, in the older children and 
adults, a considerable percentage showed a piotein reaction which had 
nothing to do with the specific toxicity of the toxin. In these cases, 
even when the mixture was overneutralized with antitoxin, this same 
pseudoreaction developed. In most cases, this reaction came on more 
promptly, covered a larger surface, was more of the urticarial type, 
had as a rule a more reddened central area and a lighter surrounding 
zone, and disappeared within two to four days. Pigmentation is absent 
or slight, and superficial scaling is very rare. In a small percentage 
however, the reaction persisted for a week or ten days and it was very 
difficult in many and impossible in some to decide between a true and 
pseudoreaction. When there was a combined reaction it was even 
harder to decide how much, if any was due to the toxin and how much 
to th3 non-toxin protein, because the development of a true reaction in 
no way prevented the protein reaction. 

Control Tests. — The best practice, therefore, in older children and 
adults is to inject the toxin in the skin of one arm, and the heated or 
antitoxin neutralized toxin in the other arm. In this way the amount 
of protein reaction can be noted, and it can be decided in the majority 
of cases whether the reaction following the toxin is a simple, true reac- 
tion, a pseudoreaction, or a combined reaction. Even after the eye 
has been thoroughly trained, it is still wise to use the two injections 
when possible. Any cases which remain in doubt are considered as 
true reactions and treated accordingly. 

Details of the Technic. — I think it is apparent to all that the technic 
of the Schick reaction, although very simple, must be carried out with 
the greatest accuracy, or the results will be entirely misleading. If the 
toxin has been diluted and stored, in a warm place, it may readily 
deteriorate and, instead of giving 0.02 of a fatal dose (M. L. D.) only 
one-half that amount may be injected, and no toxic reaction will 
occur, and the misleading idea is given that the person has been shown 
to be immune. If the toxin is incorrectly diluted, and a large surplus 
of toxin is given, slight necrosis may develop at the point of injection. 



DIPHTHERIA 105 

Use of Diphtheria Toxin in Schick Test. Directions for Using the 
Capillary Outfit. — Break off one end of the capillary tube, push the 
broken end carefully through the neck of the rubber bulb until it 
punctures the diaphragm within and enters the cavity of the bulb; 
then break off the other end of the tube. Hold the bulb between 
thumb and middle finger, place the index finger over the opening in 
the end of the bulb and expel the toxin into 10 c.c. of saline (Fig. 12). 
Rinse out the capillary tube by drawing up saline several times, then 
cork the bottle and shake the diluted toxin. Inject exactly 0.2 c.c. 
representing yV M. L. D. for the guinea-pig, intracutaneously on the 
flexor surface of the forearm or arm. The contents of the bottle are 
sufficient for about 35 tests. On account of the fairly rapid deteriora- 
tion, it is not advisable to use the diluted toxin after twelve to twenty- 
four hours. The outfit must be kept very cold to prevent deterioration. 




Fig. 12. — Method of using capillary tube and rubber bulb. Toxin in middle forced out. 

A uniform technic in the intracutaneous injection is essential in the 
Schick test. A good guide for the insertion of the needle into the 
proper layer of the epidermis is to be able to see the oval opening of the 
needle through the superficial layers of cells. A definite, wheal-like 
elevation, with the distinct markings of the openings of the hair-follicles, 
shows that the injection has been made properly and that the fluid is 
confined to a small area of the epidermis. Here it will exert its irritant 
action, if the individual tested is not immune to diphtheria. 

Syringes and needles: Preferably a 1 c.c. " Record" Tuberculin 
Syringe, and a fine platinum-iridium or steel needle. An ordinary 
hypodermic syringe with a fine steel needle may be used in emergencies. 

On two occasions when the test was employed elsewhere in New 
York State the directions for diluting the toxin were not read, and 
some hundreds of people received undiluted toxin and developed very 
sore arms. The neutralized or heated toxin, used for the pseudoreac- 
tion, must also be prepared with care. 

To carry out the test, it is essential to have an accurate syringe, with 



106 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

a sharp, but short-pointed, fine needle. Most persons prefer a needle 
with a length of one-half inch. The usual 1 c.c. "Record" tuberculin 
syringe, with a fine platinum-iridium needle ; answers the purpose well. 
The Research Laboratory places a standard diphtheria toxin in capil- 
lary tubes in such amount that the contents of one tube added to 10 
c.c. of water gives the required dilution. The dilution will keep in the 
ice-box with little deterioration for at least one day. When bulk toxin 
alone is at hand, further dilutions are made in normal saline, of such 
strength that 0.1 or 0.2 c.c. contains 5V M. L. D. for the guinea-pig. 
As already stated, Schick prefers a bulk dose of 0.1 c.c. while we prefer 
0.2 c.c. This amount is injected, intracutaneously, on the flexor 
surface of the arm or forearm. The persistent pigmentation for several 
weeks which often results may make selection of the forearm in women 
slightly objectionable. 

Interpretation of Reaction. — Though the intensity of the reaction 
varies in different individuals, a well marked persisting redness indicates 
an almost complete absence of antitoxin in the individual tested. 
Faint reactions lasting three to seven days point to the presence of 
very small amounts of antitoxin, which are not sufficient, however, to 
certainly protect the individual against diphtheria, but are sufficient 
to protect from systemic intoxication. To prevent the appearance of 
the reaction, according to Schick, the presence in an individual of at 
least ^0 unit °f antitoxin per c.c. of blood is required With the 
toxin dilution we employ, j-q unit will prevent a reaction. According 
to v. Behring., even as little as T -g~o unit of antitoxin will protect against 
the disease in uncomplicated cases. In a child three years of age, 
weighing 35 pounds, we found that a subcutaneous injection of 10 units 
of antitoxin was sufficient to prevent the appearance of the Schick 
test when made twenty-four hours after the injection of antitoxin. 

The Practical Value of the Schick Reaction. — The Schick reaction, 
has been carried out by us, during the past five years, on all patients 
entering the scarlet fever pavilion of the Willard Parker Hospital. 
Only cases giving positive reactions were immunized against diphtheria; 
those giving a negative reaction received no immunization, but were 
carefully observed. Although many of the negatively reacting 
patients became carriers of virulent diphtheria bacilli during their stay 
in the wards, no cases of clinical diphtheria developed among them. 
The patients who gave positive reactions received, in practically all 
cases, injections of diphtheria antitoxin. Previously to adopting this 
practice all patients were given antitoxin because without doing so 
about 6 per cent, of the cases developed diphtheria. 

The percentage of individuals susceptible to diphtheria is shown by 
the Schick test to be greatest between the ages of one and two years. 
It is less during the second six months of life, and less in older children, 
and least in adults and infants under six months. In adults living in 
New York City the positive reactions were not more than 20 per cent. 
In some institutions and in people from different races and localities 
higher percentages were obtained. 



DIPHTHERIA 107 



SUSCEPTIBILITY OF VARIOUS AGES TO DIPHTHERIA, AS INDICATED BY 
DIPHTHERIA-TOXIN SKIN TEST IN OVER 20,000 PERSONS. 

Average Range, 

susceptible. 






Age. Per cent. Schick. Positive. 

At birth 10 15 

Under 4 months .15 15 

4 to 6 months 30 20 30 

6 to 9 60 60 74 

9 to 1 year 75 65 75 

1 to 2 years 75 60 76 

2 to 3 

3 to 5 

5 to 10 " 30 8 40 

25 5 40 

20 5 42 



10 to 20 
Over 20 



65 50 70 

40 15 50 



It is interesting to compare these figures with the mortality at dif- 
ferent ages. (See page 100.) 

During systematic testing of groups of children belonging to families, 
we have been impressed with the frequency with which all the children 
of the same family gave a similar reaction. If variations were found, 
the younger children, with the exception of the baby, always gave the 
positive reactions. If the youngest child had a negative reaction, all 
the older children were also negative. On the other hand, if the 
oldest child in a family gave a positive reaction, the younger children 
always showed positive reactions. In a very few persons the skin 
seems to be a little less sensitive to the toxin than the average person, 
so that an unusually small amount of antitoxin prevents a positive 
reaction. 

Permanence of Negative Reaction in Persons Developing Natural 
Immunity. — The value of the Schick reaction as a practical guide in 
judging the immunity of persons depends on the duration of this con- 
dition. If natural immunity developed in children lasted only a few 
weeks or months, the value of the Schick test would be in the immediate 
emergency of an outbreak of diphtheria when sufficient time was 
available to make the test in order to inject antitoxin or separate 
from danger those who showed a positive reaction. If, however, a 
child or adult developing natural immunity holds that immunity for 
life, the knowledge that it gives a negative Schick reaction is of value, 
not only for the present, but for the rest of the individual's lifetime. 
For the past five years w T e have been testing and retesting thousands 
of children and hundreds of adults and keeping records. We found 
that, with few exceptions, those who gave a negative Schick test 
continued to show immunity during the year. From this and the 
fact of the age distribution of immune children in families in which the 
younger have a positive reaction and the older children and adults a 
negative reaction, it would seem that when once a child develops 
natural immunity this is a usually lifelong possession. It is true that 
we have found, during the five-year period mentioned an annual 
change in about 4 per cent, of the cases noted to have had a negative 



10S PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

Schick reaction, have shown a positive reaction. It is my belief that 
all of these supposed changes in reaction are not actual but are due to 
the reading of the reaction at different intervals of time after the 
toxin injection. More careful observations in the future will show 
whether this opinion is correct or not. Where the same observer 
made the tests, the changes from negative to positive reaction were 
not over 3 per cent. In tests of small groups of adults, while in most 
no change at all occurs, there is occasionally one showing as much as 10 
per cent, of change from a negative to a positive reaction. Although the 
lapse of natural immunity is so infrequent it is wise to retest young 
children or older persons who have just been or expect to be in direct 
contact with diphtheria if more than three months has elapsed since 
the test. I know of one nurse who contracted a moderate diphtheria 
seven months after a negative Schick test. Six weeks after recovery 
the nurse showed a positive reaction. 

A matter of much practical importance is whether a person with 
sufficient antitoxin to give a negative reaction has sufficient to prevent 
the development of diphtheria. We have been so in the habit of 
considering that a positive culture on Loeffler's blood serum indicated 
that the suspected case had diphtheria, that we have lost sight of the 
true fact, w T hich is, that such a culture simply indicates that the case 
is a carrier. By tests we know that the bacilli found in many are 
absolutely non-virulent. It is also an undoubted fact that a person 
w T ho is a carrier of virulent or non-virulent diphtheria bacilli may be 
afflicted with a septic tonsillitis, due to the streptococci or other micro- 
organisms. When a case of doubtful diphtheria has a negative Schick 
test and a positive culture, it is extremely difficult to decide how to 
consider the case. From the practical standpoint, antitoxin should 
be given if the case is at all serious because there is always a possibility 
that there has been some error in the technic of the test, or in its reading, 
or some mistake as to the identity of the individual. From the scien- 
tific viewpoint, the matter is of special interest. During the five years 
we have used the Schick test, no cases of severe diphtheria have 
developed in persons known to have had a recent negative Schick test, 
while some eight cases of moderate tonsillar infection with diphtheria 
bacilli have been observed in such individuals. 

In all but two of these cases, no antitoxin was given, and recovery took 
place, as in similar cases of doubtful diagnosis in which no diphtheria 
bacilli were to be found in the cultures. In an adult who had given 
a negative Schick test eleven months previously a characteristic 
moderately severe case of diphtheria developed. This and the nurse 
mentioned above are the only undoubtedly true cases that I have per- 
sonally encountered. It seems safe to rely on the belief that a person 
with a sufficient amount of antitoxin to give a negative Schick test is 
incapable of developing constitutional toxemia, or a severe infection 
from diphtheria bacilli. There is a doubt as to whether very slight 
infections of the superficial mucous membrane may occur in such 
persons. My own opinion is that the great majority of cases supposed 



DIPHTHERIA 109 

to he of this character are instances of streptococcus infection, the 
diphtheria bacilli being 1 present as in a carrier. In a home for found- 
lings seven very young children living in one portion of the building 
developed tonsillitis with patches. Six of these had diphtheria bacilli: 
one had none. All recovered quickly. Two received no antitoxin. 
In other parts of the building there were many carrier- but no tonsil- 
litis. Those that show a faintly positive Schick test are liable to mod- 
erate local infections. Careful observations of these persons with faint 
reactions will allow us, in time, to decide whether they require immu- 
nization. If this is given, it should be produced by antitoxin for the 
immediate danger, and by toxin-antitoxin for later and permanent 
effect. It takes from five to six weeks to develop active immunity by 
the use of toxin-antitoxin. My own opinion is that except in the case 
of young children it is not advisable to inject these faintly positive 
cases. 

The property of diphtheria toxin partially neutralized by antitoxin 
after injection in animal- to produce antitoxin immunity became 
known to a number of investigators in 1895 and 1896 through attempt- 
ing to use test animals that had recovered from the effect of slightly 
underneutralized test mixtures of antitoxin and toxin. Werneeke in 
1895 reported that even fully neutralized toxins were effective for 
this purpose and that the young of these innnune animals also possessed 
antitoxin immunity. In the following year I duplicated his results. 
Dreyer and Madsen in 1901 produced through similar injections in 
horses and goats serum of very considerable potency. The observa- 
tions of Renins on rabbits when added to those of other observers 
developed the fact that animals which have traces of antitoxin naturally 
respond in a few days to the stimulus of the neutral mixtures, while 
those which have none require four to six weeks. The guinea-pig 
and rabbit have no natural antitoxin while the horse and the goat 
usually possess it. In 1903 I began the use of toxin-antitoxin mixtures 
as a method of safely immunizing horses. 

In 1905 Theobald Smith suggested in a publication that human 
beings might be immunized, but the time was not ripe. Experimental 
bleedings had demonstrated that two-thirds of infants beyond the age 
of nine months possessed no antitoxin, but there was no way to detect 
those that were susceptible except through bleedings and no method 
to determine the result of injections except by the same troublesome 
method. The introduction of the Schick test for antitoxin immunity 
by the intracutaneous injections of minute doses of toxin completely 
altered conditions. It became immediately practicable to test large 
numbers of people, so as to detect those having no antitoxin and to 
watch what changes if any follow toxin-antitoxin injections. 

Behring and some of his associates were the first to attempt to 
immunize human beings with the neutralized toxin. His results were 
published in May. 1913. These while very incomplete were on the 
whole favorable. We began to use the human injections immediately 
after Behring 's report. The most important problems to be worked 



110 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

out were the exact degree of neutralization of toxin by antitoxin which 
would be most effective, the number and amount of the injections, the 
time of appearance, the extent and the duration of the immunity, the 
effect on the immunizing response to the vaccine of giving a simul- 
taneous injection of antitoxin in another portion of the body, the 
reaction of the tissues in persons of different ages, the response in 
infants who are passively immune • through the transfer to them of 
antitoxin from their mothers and finally the degree of local and con- 
stitutional protein reaction necessary. 

The best degree of neutralization was tested out by trying different 
mixtures in guinea-pigs and horses. The following table gives the 
principal points of interest in one test. 

The results of this and other experiments convinced us that a 
mixture that had sufficient antitoxin added to just rob the toxin of 
any poisonous effect even when given in large doses was as effective as 
one that was slightly toxic. Although in the amount that it is given a 
mixture which would be slightly toxic in large doses in a guinea-pig 
would probably be perfectly safe in an infant, it is nevertheless a great 
satisfaction to be able to use an effective non-toxic product. A useful 
point in the manufacture of the product is that a very slightly toxic 
mixture before filtration through a stone filter is just suitable for use 
after such treatment. As is clearly seen in the table it is not well to 
overneutralize, since the product becomes less and less stimulating of 
the production of antitoxin, as the excess of antitoxin increases. 



ANTITOXIN PRODUCTION IN GUINEA-PIGS RECEIVING TOXIN-ANTITOXIN 
MIXTURES, HAVING DIFFERENT DEGREES OF NEUTRALIZATION. 



To each unit 
of antitoxin 

was added 
toxin 

L + dose. 

0.80 . 
0.80 . 
0.70 . 
0.60 . 
0.60 . 
0.50 . 
0.40 . 



Number 
of pigs. 



Units of 

antitoxin in 

mixture. 

1 
3 
1 

1 
3 

1 
1 



L + doses 
toxin in 
mixture. 

0.80 
2.40 
0.70 
0.60 
1.80 
0.50 
0.40 



Result as 
to life, 
died- 

7 
5 



Toxin resistance 

of guinea-pigs at 

three months, 

m. 1. d. 



1.2 



Immunity persisted almost unchanged for six months and was not much diminished 
at seven months. It was not evident after twelve months. 



The size of the injection : This was tested in different animals and in 
man. It was found that moderate doses gave considerably better 
results than small doses. When the amounts given were greatly 
increased some additional response was noted, but not sufficient to 
make it wise to risk in man the objectionable protein reactions which 
develop in a certain proportion of persons injected. We finally decided 
on a 1 c.c. dose when it was possible to give three injections. The 
toxin used had a minimal fatal dose of about .0025, and an L+ dose 
about .40. A somewhat weaker or stronger toxin could equally well 



DIPHTHERIA 



111 



be used if the amount of fluid was adjusted proportionately. The 
local reaction is due almost wholly to the autolyzed bacillus substance 
and other proteins in the culture fluid which are not related to the 
specific toxin. Attempts to remove these undesirable substances have 
already been partially successful. The number of injections: Each 
added injection gives an additional antitoxin response. For practical 
purposes it is necessary to restrict the number to as few as possible. 
This therefore has to be worked out by observations on human beings. 
Many hundreds of tests have demonstrated that from one injection 
we may expect at the end of three months about 70 per cent, of positive 
Schick persons to develop enough antitoxin to change to negative test. 
Two injections will change about 80 per cent, of the positive Schick 
cases and three about 90 per cent. If a second series of these injections 
are given to the refractory cases about 80 per cent, will respond. 
Even this remainder of 2 per cent, can be immunized by further 
injections. At the end of six months a somewhat larger percentage of 
negative cases will be found. Under different conditions one, two or 
three injections may be desirable. 'We try to give three when possible, 
but often have to be satisfied with two or even one. 

RESULTS IN ACTIVE IMMUNIZATION AT SIN WEEKS AND THREE 

MONTHS. 



No. of Amount, 


Schick retest (six weeks). 


Schick retest (2 to 3 months). 


doses. c.c. 


No. of cases. 


Immune. 


No. of cases. 


Immune. 


1 . . . 1 1.0 

2 . . . 1.0 

3 . . . 0.5 
3 . . . 1.0 


75 

33 

28 

183 


51 (68.0 per cent.) 

28 (84. 8 per cent.) 

25 (89. 3 per cent.) 

156 (85. 2 per cent.) 


239 
89 
28 

201 


175 (73. 2 per cent.) 
80 (90.0 per cent.) 
26 (92. 7 per cent.) 

191 (95.0 per cent.) 



The time of the appearance of the antitoxin: A very 
discovery was quickly made that warm-blooded animals which have 
traces of natural antitoxin produce very considerable amounts within 
five to seven days, while those which have none require from four to 
twelve weeks before appreciable amounts accumulate in the blood. 
The antitoxin content of the blood in iminunized horses drops back to 
the original amount in about nine months. Some human beings have 
and some have no natural antitoxin, there are therefore among them 
those which respond quickly and those which respond slowly. Ths 
interesting fact developed that while those receiving injections which 
previously had antitoxin dropped as the horses in a year to their original 
amounts, those that had none continued to produce sufficient new 
antitoxin to give immunity. 

The late development of antitoxin in those having a positive Schick 
test impresses the truth that toxin-antitoxin cannot take the place of 
injections of antitoxin when there is immediate danger of infection. 
Diphtheria antitoxin gives immediate and absolute immunity for a 
short period. Toxin antitoxin gives immunity after a lapse of from 



112 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

one to three months and for a long period. Each therefore has its 
important part in the prevention of diphtheria and one supplements 
the other. 

Bactericidal and antitoxic immunity: Immunity to diphtheria may 
be due to the presence of antitoxin or of bactericidal substances. The 
majority of those who recover from diphtheria have not developed 
at the time any appreciable antitoxin. We discovered this by resting 
convalescent cases that had recovered without antitoxin treatment. 
The immunity developed from the toxin antitoxin injections is almost 
wholly antitoxic. If sufficient antitoxin develops, it is as effective 
as a larger amount. Several investigators have measured the amount 
of antitoxin in a number of immunized cases. The following table 
gives some of Zingher's and Schroder's determinations: 



Institution. 


Number 

of 

injections. 


Number 

immuned 

tested. 


Age at time 


Since 
injections, 

lapsed 
time, yrs. 


Result. 


Immunity, 


of injection. 


+ 


rfc 


rfc 


- 


per cent. 


1. Lying-in Hosp.J 

2. Milk Station . 

3. Leake & Watts 

4. Hebrew Orphan. 

5. House of Refuge 

6. St. Dominic 

7. St. Dominic 

8. St. Joseph's . 


2 and 3 
3 
3 

1 and 2 

2 and 3 
2 and 3 

1 
2 and 3 


167 
350 
32 
68 
49 
38 
10 
38 


3 days 

2 /i2 to 4 yi 

5 to 15 

5 to 15 

10 to 20 

4 to 12 

4 to 12 

5 to 10 


"S. 


1 /100 

'/a 

26/12 

2F/ M 
2»Ai 

3 2 /l2 
2 7 /l2 

32/12 


146 
37 

*3 

4 
2 
3 


2 

2 
1 


3 

4 
2 
3 


21 
313 
26 
59 
42 
33 
7 
38 


13 
77 
94 
93 
89 
95 
70 
100 



1 The babies in the Lying-in Hospital were not Schick tested. Fully 90 per cent, would undoubt- 
edly give a negative reaction. All others injected gave a positive Schick just before treatment. 
The average percentage of negative Schick tests at twelve months is about 25 per cent. The 13 
per cent, in the injected cases is, therefore it indicates that at this early age the vaccine produced no 
results. 



.The Duration of the Immunity — This can only be determined after 
the lapse of years as the first to be immunized still possess antitoxin. 
No reports have been received from the persons receiving the first 
injections in Germany. Our observations, therefore, probably extend 
over the longest period of time. These are upon positive children in 
institutions which were immunized by Dr. Zingher from three to four 
years ago. He tested the results after one and two years. In his 
absence Dr. Schroder tested them last year. Each year some of the 
children leave the institutions and are lost track of so that the figures 
on the cases observed for three years or longer are rather small. For- 
tunately the results ar3 so similar in the different groups that we can 
probably safely rely upon the moderate number of observations. It 
is remarkable how well the immunity persists. There has been almost 
no change from year to year. It appears as probable that the vaccine 
has not only stimulated a production of antitoxin, but has aroused the 
cells to an activity which had before remained dormant, so that these 
persons who before made no antitoxin join the larger group who nor- 
mally produced it. There is so far as I know no explanation of the 
making of natural antitoxin. The fact that it develops in the children 
of most families at a certain age and that it is present in the great 
majority of horses and many other animals excludes the possibility 



DIPHTHERIA 113 

that it is generally due to the stimulus of diphtheria bacilli, present in 
the throat without producing disease and therefore undetected. 

The effect of giving in different portions of the body antitoxin and 
toxin-antitoxin simultaneously: The fact that in man and in animals 
the members that have antitoxin present in their bodies react to the 
T. A. injections is sufficient proof that antitoxin in the circulating 
fluids does not prevent injection of T. A. from stimulating additional 
antitoxin. 

Horses as they accumulate antitoxin during immunization continue 
to receive stimulus from continued injections of toxin. It is true, 
however, that larger amounts are required to exert the necessary effect. 
The presence of antitoxin lessens therefore somewhat the effectiveness 
of the stimulus of an equal amount. We have not made sufficient 
observations on young infants to be certain of the degree to which the 
presence of antitoxin diminishes the response. That it has some effect 
is clear. Given after the toxin-antitoxin it has no inhibiting effect. 
Two institutions gave very interesting results. In one the antitoxin 
was given at the same time as the first injection. In the other simul- 
taneously with the second. In the first the results were only half as 
good as usual while in the later case no inhibition was apparent. 

The Reaction at Different Ages. — The baby of an immune mother 
is immune because of the passive transfer of antitoxin as well as other 
antibodies. Sometime during the first year it usually completely 
eliminates the mother's antitoxin. Later as a rule its own cells develop 
it. The infant may differ from an older child in another way. Besides 
having antitoxin from its mother, its cells may not yet have acquired 
the ability of producing antitoxins. Infancy is the time of life at which 
we would like to immunize because diphtheria is chiefly a disease of the 
early years of life. The problem to solve as to the earliest age that 
practical immunization can be carried out is therefore a very important 
one. 

Last year we injected 2100 infants on the third, sixth and ninth 
days after birth. After a lapse of twelve months we retested many of 
them and discovered that they possessed the same average immunity 
as untreated infants. This age is therefore too young. We have 
immunized many non-immune infants of an age from six months to one 
year and have found them as readily immunized as the older children. 
The degree of local and constitutional reaction to the injections: 
Our observations have convinced us that the reactions are due chiefly 
at least to the proteins other than the toxin. Even if the toxin itself 
produces any local or constitutional disturbance it must be as a general 
protein and not as a specific toxin for the latter has been neutralized so 
as to possess no specific toxic power. The protein reaction is absent in 
the newly born, infrequent in the young child and more frequent in the 
older child and adult. There may be an indurated, reddened and pain- 
ful area of several inches in extent. Except on one occasion when by 
accident a contaminated product was given abscesses have not occurred. 
On this occasion out of some two hundred children injected twelve 
8 



114 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

develo]x^d superficial localized abscesses. " No permanent deleterious 
results have been met with. We are now trying a preparation made 
from the precipitated toxin-antitoxin. The protein reaction is much 
less. When perfected this refined product will probably be the only 
one used. The Department of Health and the Department of Educa- 
tion have united in a campaign to eradicate diphtheria. It may be of 
interest to include here a circular given to all the children in the 
primary classes of one hundred public schools in May of this year. 

DEPARTMENT OF HEALTH. DEPARTMENT OF EDUCATION. 

City of New York. 

Children who attend the schools are guarded as carefully as possible by school 
nurses and teachers from disease. Nevertheless, they come so closely in contact 
with each other, that they are likely to carry infectious diseases and to transmit 
them to one another. 

Diphtheria attacks nearly 12,000 children every year, and causes the death 
of nearly 10 per cent, of these (or about 1200 children). We are now reasonably 
certain that we know how to protect your child against this disease, IF YOU 
WILL HELP. 

By injecting one drop of a test liquid under the skin of the child, we can tell 
within two or three days whether your child is naturally protected against diph- 
theria, or whether it is readily capable of catching the disease. If the child is 
safe, nothing need be done. If it is not safe, we can make it so by three harmless 
injections given at intervals of a week. The child will then probably be protected 
for life. The test is simple, free from all danger, and will not make your child 
sick. This is a safe thing to apply no matter how young the child is. Diphtheria 
can be practically wiped out among children who receive this treatment. 

If you want to protect your child and not blindly trust to luck, then don't 
wait. Let your family doctor apply the test at once and give you a certificate 
showing that your child has been tested, stating whether or not it is safe from 
diphtheria. If it is not safe, let your doctor at once give the three injections 
that will practically guarantee protection. 

If you cannot obtain the services of a private physician, sign the slip attached 
below and a Health Department physician will apply the test and the remedy. 

If you want the Health Department doctor to apply the test and the remedy, 
sign the following: 



CONSENT FOR SCHICK TEST AND IMMUNIZATION. 
I hereby consent that of 

(Name) (Address) 

may receive from the Department of Health physician the test to determine if the 
child is liable to contract diphtheria. If found to be in danger of contracting this 
disease, I consent that the protective vaccination be given 



Dated, New York 19 

(Parent) (Guardian) 

It is expected that these measure^ will be introduced into all the 
New York City schools next fall, 






SMALLPOX 115 



SEPTIC SORE-THROAT. 



Streptococcic infection of the throat appears at times as a severe 
epidemic. Most of these epidemics have been traced to the milk 
supply. 

Infectious Agent. — The infectious agent is the hemolytic type of 
streptococcus. The bovine streptococcus produces mastitis in cows, 
but does not cause septic sore-throat in man, unless a secondary infec- 
tion of the udder by a human type of streptococcus takes place. In 
such cases the cow acts as a carrier of human streptococci, and the 
milk-borne outbreaks are usually prolonged. 

Source of Infection. — The source of infection is the human naso- 
pharynx, usually the tonsils; any case of acute streptococcic inflamma- 
tion of these structures being a potential source of infection, including 
the period of convalescence of such cases. The udder of the cow 
infected by the milker is an occasional source of infection. In such 
cases the physical signs of mastitis are generally absent. 

Mode of Transmission.^-The mode of transmission is by direct or 
indirect human contact, or by consumption of raw milk from an 
infected udder. 

Incubation Period. — The incubation period is one to three days. 

Period of Communicability. — The period of communicability in man, 
is presumably during the continuance of the clinical symptoms; in the 
cow, during the continuance of discharge of the streptococci in the 
milk, th? condition of the udder tending to a spontaneous subsidence. 
The carrier stage may follow convalescence and persist for some time. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the Disease by the clinical symptoms, assisted by 
bacteriological examination of the lesions or discharges from the tonsils 
and nasopharynx. 

2. Isolation of the patient during th? clinical course of the disease 
and convalescence and particularly by the exclusion from participation 
in the production or handling of milk or milk products. 

3. Concurrent disinfection of articles soiled with discharges from the 
nose and throat of the patient. 

II. General Measures. — 1. Exclusion of the suspected milk from 
public sale or use, until pasteurized. The exclusion of the milk of an 
infected cow or cows in small herds is possible when based on bacterio- 
logical examination of the milk of each cow, and preferably the milk 
from each quarter of the udder, at frequent intervals. 

2. Pasteurization of all milk. 

3. Education in the principles of personal hygiene and avoidance of 
the common towel, drinking and eating utensils. 

SMALLPOX. 

Smallpox (Variola). — An acute infectious disease characterized by 
an eruption of papules, vesicles and pustules, which upon healing 



110 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

produce typical scars on the skin of varying depth and extent. It is 
highly contagious and controlled only by vaccination. 

The exact nature of the exciting factor in smallpox is undetermined. 
Certain "vaccine bodies" found chiefly in the epithelial cells of the 
skin and mucous membranes in the specific lesions have been claimed 
to be protozoa causing the disease; but opinions still differ as to this. 

The diseases smallpox, cowpox, horsepox, sheeppox, if not identical 
are closely allied. Experiments, indeed, have demonstrated that at 
least cowpox and smallpox are very nearly related, if not essentially the 
same disease. Several experimenters believe they have changed small- 
pox virus into cowpox. We have not been able to make this trans- 
formation. The virus used by the Department of Health has been 
transferred from cow to cow for at least thirty years and is believed 
to have come originally from cowpox. 

Incidence. — Smallpox was for many centuries one of the greatest 
scourges of the human race. It was more common than measles and 
much more fatal. It is believed that in the 18th century every tenth 
death was du^ to smallpox. More than 500,000 are known to have died 
each year. Formerly smallpox was a children's disease, but since 
vaccination has protected the child, it has become somewhat more 
prevalent among adults who have received but one vaccination. No 
infectious disease shows a more complete independence of conditions, 
such as race, climate, soil, age, sex, occupation and sanitary surround- 
ings, than does smallpox. It thrives wherever the infection is carried, 
and wherever it finds susceptible persons. Apparently no one is 
naturally immune. One attack ordinarily protects against another, 
but not necessarily; second and even third attacks are known. The 
disease occurs in epidemics of varying extent and severity, which often 
recur in waves. The reason for this is partly because of the number 
of unvaccinated persons who have had the disease and have been left 
immune. There seem to be also different strains of smallpox. In the 
same community the cases from a first focus will be on the average 
very light, while those from a second focus will be quite severe. The 
same is true of typhus fever. The endemic disease is of a much milder 
type than the imported. 

Transmission. — Smallpox is probably transmitted by more or less 
direct contact, although the precise method of the conveyance of infec- 
tion is unknown. The infection gains entrance into the system through 
the respiratory tract. The virus has been shown experimentally to be 
contained in the lesions of the skin and mucous membranes. The dis- 
ease is infectious before the eruption appears, and for this reason it has 
been assumed to be present in the expired air; but this assumption has 
never been substantiated. Although the virus, as dried infected epi- 
thelium, is doubtless air-borne, the radius of infection is probably 
limited to the immediate neighborhood of the smallpox patient. There 
is no evidence to show that the infection is carried by the air to any 
distance or outside of the sick room. It is certainly not conveyed out- 
side of the building occupied by the patient, as has sometimes been 
supposed. 



SMALLPOX 117 

Apart from more or less direct contact, smallpox infection may be 
spread by secretions from the mouth and nose. Fomites or objects 
which have become contaminated by the infective virus, such as eating 
utensils, towels, handkerchiefs, bed linen, and the like, may convey 
the infection; but the danger from this source is probably comparatively 
slight. Flies and other insects may act as mechanical carriers. 

Prevention and Control. — The prevention and control of smallpox 
depend first upon vaccination, and second upon general sanitary meas- 
ures, such as registration, isolation and disinfection. 

Vaccination. — This consists in the transference of the living virus or 
active principle from the skin eruption of an animal having cowpox or 
vaccinia into the skin of a susceptible animal or man to prevent small- 
pox or variola. The disease thus produced (cowpox) is a modified form 
of smallpox. Cowpox is a mild infectious disease, characterized by 
a local eruption confined to the site of the vaccinated area, and accom- 
panied usually by slight constitutional symptoms. When uncompli- 
cated, death has never been known to be caused by cowpox. Jenner 
having had his interest aroused by the reports of farmers that an 
attack of cowpox gave immunity to smallpox made a thorough scien- 
tific investigation. In 1796 he transferred vaccine matter from the 
hand of a dairy maid to the arm of a boy. A typical take followed. 
He was inoculated six weeks later with smallpox virus. No take devel- 
oped. Ten individuals who had cowpox, some one to fifty years before, 
were inoculated with smallpox without result. These tests established 
the value of cowpox vaccination. Gradually it supplanted the inocula- 
tion with smallpox virus. 

Vaccine Virus. — Vaccine virus may be obtained from man, calves, 
rabbits and other animals. Human virus is now seldom used, chiefly 
because the supply would be inadequate, and also because of the pos- 
sibility of conveying infection from diseases peculiar to man, such as 
syphilis. Bovine virus has always been more or less used since the 
time of Jenner, its discoverer, but since Copeman in 1891 showed that 
it could be purified with glycerin, it has come into general use. 

Preparation of the Virus. — Vaccine virus may be used fresh, dry and 
glycerinated. The fresh virus, taken from the eruption of the calf or 
man and transferred directly, is still used to some extent in France. 
Dry virus is now not used at all. Glycerinated virus is the form at 
present preferably employed for vaccination. It consists of the vaccine 
pulp, or entire vesicle with its contents, treated with 50 per cent, pure 
glycerin. The addition of glycerin preserves the active principle of the 
virus and destroys the non-sporebearing bacteria, thus purifying it. 

Fresh vaccine virus is said to be "green." When glycerin is added to 
the pulp and allowed to act upon it for a certain time, the virus is said 
to be "ripe." The addition of glycerin weakens the virus and finally 
destroys it. Vaccine virus should therefore not be used when green, nor 
when too old. Seed virus may be produced: (1) from glycerinated 
bovine virus which has been ripened for two or three months; (2) from 
rabbit virus, or the virus of rabbits vaccinated with stock bovine virus; 



118 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

(3) from human virus, or lymph collected from the vesicles of pre- 
viously unvaccinated children; (4) from glycerinated virus from calves 
which have been vaccinated with an emulsion of human vaccine crust; 
(5) from human-calf-rabbit virus, which in the Vaccine Laboratories 
of the New York City Department of Health has been found to be the 
most economical, efficient and reliable. 

This human-calf-rabbit seed is produced as follows: 

( rusts are collected from healthy children about nineteen days after 
vaccination. These are cut up and emulsified into a paste with boiled 
water. This humanized seed is then inoculated into a small area of a 
calf's abdomen. The pulp from this special area is separately collected 
and glycerinated. It is then tested bacteriologically and clinically. 
This bovine virus from human seed is now used (in a dilution of 1 part to 
12| parts of normal salt solution) to vaccinate rabbits. Five days after 
vaccination the pulp is removed with a curette, weighed and emulsified 
with a solution of glycerin (50 per cent.), sterile water (49.5 per cent.), 
and carbolic acid (0.5 per cent.), in the proportion of 1 part of pulp to 
8 parts of the solution. The regular supply of vaccine virus is produced 
by vaccinating calves (preferably females from two to four months old) 
with this rabbit seed. 

The calves are vaccinated and the vaccine pulp collected under 
careful antiseptic conditions. The calves are inspected by a veteri- 
narian at the time of purchase for such diseases as tuberculosis, glanders, 
foot-and-mouth disease, tetanus, skin diseases, etc. After the vaccine 
has been collected, the calves are immediately killed and their organs 
examined by the veterinarian. If at autopsy, an animal be found dis- 
eased, the vaccine is discarded. The calves are specially cared for in 
vaccine stables with concrete floors and stalls, which are kept flushed 
with water to wash away dejecta. They are fed on milk, no hay or 
straw being used for any purpose. 

The vaccine pulp when collected is placed in sterile glass containers, 
packed in ice and shipped at once to the vaccine laboratory. As soon 
as received it is ground up and emulsified in the solution of glycerin, 
sterile water and carbolic acid as before described, and then tested for 
purity, for gas-forming organisms, for tetanus, and for streptococcus. 
After all the laboratory tests for purity have been made and found 
satisfactory, the vaccine is ready for use upon human beings, provided 
it be found to be efficient clinically. To determine this point inocula- 
tions of the vaccine are made upon previously unvaccinated children, all 
of whom must show a perfect take; and these clinical tests are made 
every two weeks as long as the vaccine is in use. If one test fail, the 
vaccine is called in. 

Vaccine virus is put up in special containers, such as glass vials or 
capillary tubes, and on glycerinated points or strips of bone or other 
material dipped in the glycerinated virus. Packages of these are kept 
in an ice-box at a temperature of 33° to 40° F., ready for issue. 

Methods of Vaccination. — Vaccination is to be considered as a surgical 
operation and performed accordingly. The inoculation may be made: 



SMALLPOX 119 

(1) by puncture with a needle moistened with the vaccine, which is the 
simplest method, but not always successful; (2) by scarification or 
cross-scratching with a vaccine point or needle dipped in the lymph, 
which has the objection of producing an abraded surface soon covered 
by a crust, through which the eruption penetrates with difficulty, and 
of causing possible infection under anaerobic conditions favorable to 
the development of tetanus; and (3) by incisions, which is the prefer- 
able method, and they are now commonly employed. 

The incisions may be made with a sharp scalpel or knife, but better 
with a needle. They should not be so deep as to draw blood, although 
a few drops of blood do not matter. The circular issued by the State 
Department of Health is so excellent that it is given entire: 

How Vaccination is to be Performed and Reported. — Chapter 133 of 
the Laws of 1915, winch amended Sections 310 and 311 of the Public 
Health Law, specifies that no child or other person shall be admitted 
into any school in a first or second-class city unless it has been vaccinated. 
In third-class cities, towns and villages the vaccination of school 
children is compulsory only when the State Commissioner of Health 
has specified in writing to the school authorities in any municipality 
that smallpox exists in the school district or in the vicinity thereof. 

The Law provides that vaccination shall be performed only by a 
regularly licensed physician, and in such manner as is prescribed by 
the State Commissioner of Health; that no vaccine virus shall be used 
unless produced under license issued by the Secretary of the Treasury 
of the Lnited States and accompanied by a certificate of approval by 
the State Commissioner of Health. Every physician performing a 
vaccination shall also make a report to the State Commissioner of 
Health upon a form furnished by the Commissioner within ten days 
of the date of vaccination. 

The vaccine virus shall be used within one year of the time it is 
issued for use and not later than the date (stamped upon each vaccine 
virus outfit) when the virus should be active. 

Age at Which Vaccination should be Performed. — It is recommended 
that every infant should be vaccinated during the second six months of 
life and only when in good health; and that all persons be revaccinated 
whenever smallpox exists in any community. It is also recommended 
that vaccination be performed, insofar as is possible, between the 
months of October and June. The investigations of the accidents and 
complications which very rarely follow vaccination show that they are 
more likely to occur during the summer months and in children who 
are running about. 

Cleanliness is absolutely essential. The site of vaccination and the 
physician's hands should be thoroughly cleansed with soap and water 
and allowed to dry. When the child is dirty it is recommended that it 
be given a full bath and dressed in clean clothing. 

Instrument to be Used. — The only instrument to be used is a new 
needle with a sharp point sterilized by boiling or by heating in a flame 
or a scalpel or platinum scarifier sterilized in a similar manner. The 



120 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

needle or vaccine point prepared by the manufacturer may also be used 
for this purpose for one vaccination if used immediately after taking it 
from its original package. 

Technic of Vaccination. — Vaccination should be performed on the 
outer surface of the upper arm opposite the insertion of the deltoid 
muscle. The outer surface of the calf may be used, but it should be 
remembered that this site is more likely to be rubbed and is thus ren- 
dered more liable to infection. A small drop of vaccine is placed on the 
spot that has been cleansed and dried, and then with the new sterile 
needle, scalpel or platinum scarifier a scarification is made, not larger 
than the end of a match, or a single scratch not more than a quarter of 
an inch long, the scarification or scratch being made through the drop 
of virus. (Cross-hatching or more than one scratch must not under any 
circumstances be employed.) The vaccination should be allowed to dry 
thoroughly in the air. No dressing should be placed on the arm. In 
the event of a "take," a dressing of clean sterile gauze or clean cheese- 
cloth may be fastened to the undergarment to protect the vaccination. 
The patient must be warned not to scratch or disturb it. No shield of 
any variety should be used. The scab should not be removed. 

Dressing. — If the dressing becomes soiled by oozing from the vac- 
cination the physician should remove the dressing and wash the area 
with a sterile salt solution or with cool, freshly boiled water. When the 
dressing is changed care should be observed not to touch the vaccination. 
A fresh sterile dressing on the inner side of the sleeve should protect the 
vaccination as before. In the usual course of vaccination dressings 
should be changed only a few times, but if there is a great deal of oozing 
they should be changed daily. Never use shields. 

Normal Course of Vaccination.- — If these directions are carried out a 
successful vaccination will take a normal course, which is as follows: 

For three or four days there will be no sensation, except possibly a 
little itching. Then a small red area forms, in the center of which a 
spot like a blister appears, and there will be some tenderness and redness 
about the vaccination area. At this time there may be some slight sore- 
ness in the armpit and some feeling of illness. There is usually some 
oozing of yellowish material. The blister gradually dries up and a thick 
scab forms. The redness and tenderness gradually subside, and after 
two or more weeks the scab falls off, leaving a pitted scar. In a few 
cases the vaccination takes a somewhat severer course, causing more 
pain and discomfort than usual, and some fever. 

Inspection and Report. — The vaccination should be inspected by the 
physician who performed the same between the fifth and ninth day 
after vaccination, and a report must be made on the form prescribed 
by the State Commissioner of Health. 

These forms will be supplied by the local health officer and the 
vaccination report card should be returned to him. 

Successful Vaccination. — Successful vaccination requires that the take 
be typical and the clinical cause characteristic. 



SMALLPOX 121 

The following are the average signs and symptoms of a typical pri- 
mary vaccination when two incisions or cross-hatching is employed: 

At the end of thirty-six to forty-eight hours there is seen at the point 
of inoculation a slight papular elevation, small, round, flat, bright red, 
hard, but superficial. This papule gradually increases in size and on 
the fifth or sixth day shows a definite vesicle. The vesicle is at first 
clear and pearl-like, the margins are slightly raised while the center 
is depressed or umbilicated. A deep, red swollen zone or areola sur- 
rounds the vesicle. By the seventh day the vesicle has attained its 
maximum size. It is round or oval, umbilicated, and contains a clear 
lymph. It is multilocular, i. e., if opened, it will be found that only 
that portion of the lymph contained in the compartment opened will 
exude. By the eighth day it is yellowish, distended with lymph, and 
a second umbilication follows. The areola deepens and widens. The 
skin is hot and painful, and the neighboring glands become enlarged 
and tender. About the ninth or tenth day the areola begins to fade, 
and the swelling decreases. On the eleventh or twelfth day, the lymph 
becomes more opaque and commences to dry. At the end of the 
second week the vesicle is converted into a brownish scab which 
eventually separates and leaves a pitted scar characteristic of cowpox. 

The constitutional symptoms following vaccination are more or less 
marked. Usually on the third or fourth day the temperature rises 
and may persist until the eighth or ninth day. In children the fever 
may be accompanied by restlessness and irritability; but as a rule 
the symptoms are trivial. If the vaccination is made on the arm, the 
axillary glands are enlarged and sore; if on the leg, the inguinal glands 
are affected. 

Immunity. — The immunity appears about the eighth or ninth day. 
Its duration is very variable, differing in different individuals. The 
earliest case on record is one nine months after a successful vaccination. 
In some instances it is permanent, but a majority of persons when ten 
years have elapsed again become susceptible. It is extremely rare for 
a person who has been properly vaccinated to have severe smallpox, 
but it sometimes happens. Smallpox itself does not always protect 
against smallpox. 

Revaccination. — The best time to make the primary vaccination is 
after six months and before the expiration of the first year. Revac- 
cination should be performed between the tenth and twelfth year. 
After this it is, as a rule, unnecessary to vaccinate again, unless there is 
danger of exposure. All persons who have been exposed in any way 
to smallpox should be immediately vaccinated, excepting those who 
within one year have been successfully vaccinated. There are no 
contra-indications. Vaccination will almost always prevent the devel- 
opment of smallpox, if taken promptly after exposure. 

Complications and Dangers. — These have been greatly exaggerated, 
but vaccination is by no means always harmless and uncomplicated. 
The vaccinia produced is usually a mild affection, but it is, nevertheless, 
an acute infectious disease, and should not be treated lightly. The 



122 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

wound, like any other small abrasion or scratch, may become infected, 
unless proper precautions are taken to prevent it, although with the 
improved quality of the vaccine now used and modern aseptic methods 
of operation, a bad sore arm and serious complications are exceptional. 

Among the more important complications are: Auto-vaccination, 
due to scratching of the virus with the fingers into the nose, mouth, 
mucous membranes, or skin, if introduced into the eye it may cause 
blindness; generalized vaccinia, produced by absorption of the virus, 
which is extremely rare; wound infections, such as ulcers, gangrene, 
erysipelas, abscess, suppuration of the axillary glands, and other septic 
infections, which now seldom occur. Tetanus may occasionally compli- 
cate vaccination, as it may any other wound. Its occurrence after vac- 
cination is thought to be due to lack of care and neglect of the wound, and 
not to the vaccine itself. Foot-and-mouth disease has been known to 
occur as a contamination of vaccine virus. Although this infection is 
not transmissible from cattle to man through cutaneous inoculation, 
this contamination is now guarded against by the Federal law requiring 
vaccine virus to be tested in order to assure freedom from this as well 
as other infections. 

Claims. — Vaccination is not claimed to be an invariable and per- 
manent preventive of smallpox, but in an immense majority of cases 
successful vaccination renders the person for many years unsusceptible. 
The period of protection has not been accurately determined. It may 
endure for life, or only for a year or two. As a safe rule to follow, 
persons should be vaccinated every eight or ten years. While the 
individual protection is not always perfect, vaccination and revaccina- 
tion systematically and generally carried out confer complete protec- 
tion to communities and nations. Should a vaccinated person later 
contract smallpox, the disease is usually in a milder form than in 
unvaccinated persons, known as varioloid. Should an unvaccinated 
person contract smallpox, and vaccination be performed about the 
sixth or eighth day of the period of incubation, it takes and may 
modify the severity of the disease. If the vaccination is done at the 
beginning of the incubation period, or in time to have the vaccine 
eruption reach maturity before the smallpox begins, it will prevent 
or abort the disease. 

Results. — Communities in which vaccination and revaccination are 
thoroughly carried out are those in which smallpox has the fewest 
victims. Since the enactment, in Germany, of the law requir- 
ing the compulsory vaccination and revaccination of all persons, 
in 1874, there have been no epidemics of smallpox in that country. 
The disease is frequently introduced by foreigners, particularly on 
the frontiers, but it can obtain no foothold. In 1897, there were but 
five deaths from smallpox in the entire German empire, with a popula- 
tion of fifty-four millions. The large German cities, Berlin, Hamburg, 
Breslau, Munich and Dresden, have a perfectly insignificant mortality 
from smallpox as compared with London, Paris, Vienna, and Petrograd, 
in all of which the vaccination laws are relatively lax. Among large 



SMALLPOX 123 

bodies of men (e. g., the German army), in which vaccination and 
revaccination is regularly practiced, smallpox is unknown. These 
facts should convince anyone of the efficacy of vaccination as a pre- 
ventive measure against smallpox. 

Registration, Isolation and Disinfection. — While general sanitary 
measures are necessary for the control of smallpox, as of all infectious 
and communicable diseases, they cannot be relied upon for the pre- 
vention of this infection. They should not be regarded as substitutes 
for vaccination in smallpox. 

Registration should include, as far as possible, all suspicious as well 
as definite cases of the disease. Chickenpox especially, on account of 
its close resemblance to smallpox, in the presence of an epidemic, 
should always be regarded as suspicious until a positive diagnosis is 
made. 1 In well defined cases of varicella the characteristic vesicles, 
the irregularity of their appearance, the short stage of invasion, the 
slight constitutional disturbance, and the greater intensity of the 
eruption on the trunk, should make the diagnosis clear. 

Isolation and disinfection should be rigorously carried out for the 
reason that smallpox is one of the most contagious of the communicable 
diseases, and also because these measures may lessen the danger of 
infection, especially when there are few cases. 

It is always best that the patient be taken at once to a special hos- 
pital, vacant house or tent. But this place of isolation need not be a 
desolate " pest-house." As there is practically no danger from the 
proximity of a smallpox hospital, it may be located in the vicinity of 
other habitations, provided, of course, the necessary precautions are 
observed to prevent the spread of the infection. 

Isolation in a private house is possible, but it should be permitted 
only if the room, in which the patient is treated, is properly screened, 
well ventilated, and so equipped that it can be kept scrupulously clean. 
A trained nurse must be in attendance and all visiting strictly forbidden. 
The food must be prepared in a separate kitchen, and special care 
must be taken that all dishes, etc., used are scalded and all remnants 
of food burned. No objects, such as bedding, towels, underwear, etc., 
must be allowed to leave the sickroom unless they are first boiled, 
steamed, or soaked in a disinfecting solution of bichloride of mercury 
(1 to 1000) or formalin (10 per cent.). Carbolic acid should not be 
depended on. All articles which may have become particularly 
contaminated by the patient before or after isolation should be burned 

1 In the first stages cf smallpox the eruption is hard and "shotty," it extends into the 
skin, while in chickenpox the vesicles are superficial and easily broken. In chickenpox 
the eruption comes out in successive crops, and there is very little eruption on the hands 
and feet. If some of the suspected virus (heated to 60° C. for 30 minutes) is inoculated 
into the skin of a successfully vaccinated individual, a typical "immediate reaction" 
occurs within a short time, if the disease is smallpox; if chickenpox, no reaction occurs. 
Histological examination of the pock, by inoculation of the contents of the vesicle upon 
the cornea of a rabbit, shows the vesicle of smallpox to be multilocular ; in chickenpox, 
it is unilocular. The vesicles of smallpox on the cornea of the rabbit are distinct and 
contain the "vaccine bodies;" the lesions in chickenpox are indistinct and do not contain 
the "vaccine bodies." 



124 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

or thoroughly disinfected; and if the patient is removed to the hospital 
or dies, the room occupied by him should receive a terminal disinfec- 
tion by sulphur dioxide or formaldehyde gas. It should finally be 
thoroughly cleansed, aired and sunned. 

The patient being the principal source of infection, all articles that 
have come in contact with his body, and particularly all dressings 
which may have become soiled with the contents of the vesicles, should 
be burned. The secretion from the mouth and nose, as also the other 
discharges from the body, urine and feces, must be disinfected with 
bichloride of mercury or chlorinated lime. Quarantine in a case of 
smallpox is usually observed until all desquamation ceases. This may 
be favored by the use of warm baths and the application of oil (cam- 
phorated oil or vaseline) to the skin. The hair, fingernails, and all 
folds and creases of the skin should receive a special cleaning before the 
patient is discharged. 

CHICKENPOX. 

Chickenpox (Varicella). — An acute infectious disease of children, 
characterized by an eruption of vesicles on the skin. 

The disease occurs in epidemics, but sporadic cases are also met with. 
It may prevail at the same time as smallpox or may follow or precede 
epidemics of this disease. Although usually regarded as one of the 
minor communicable affections of childhood, it is by no means always 
a harmless disease. It may produce cicatrices; sepsis or erysipelas 
may result; and complications, such as pneumonia, nephritis and 
gangrene of the skin may also follow. One attack confers a definite 
immunity, as a rule. But an attack of chickenpox is no protection 
against smallpox. The disease usually runs a mild course occuring 
in children between the second and sixth year. It is rarely seen among 
adults. But because it may often be mistaken for smallpox, chicken- 
pox should be a reportable disease. 

Infectious Agent. — The infectious agent is unknown. 

Source of Infection. — The source of infection is presumably in the 
lesions of the skin and of the mucous membranes; the latter appearing 
early and rupturing as soon as they appear, render the disease com- 
municable early, that is, before the exanthema is in evidence. 

Mode of Transmission. — The mode of transmission is directly from 
person to person, and indirectly through articles freshly soiled by the 
discharges from an infected individual. 

Incubation Period. — The incubation period is from two to three weeks. 

Period of Communicability. — The period of communicability is until 
the primary scabs have disappeared from the mucous membranes and 
the skin. 

Methods of Control. — The Infected Individual and his Environment. — 
1. Recognition of the Disease by the Clinical Symptoms. — The differen- 
tial diagnosis of this disease from smallpox is important, especially in 
people over fifteen years of age (see Smallpox). Monkeys cannot be 
vaccinated with virus from chickenpox, but can be from smallpox. 



MEASLES 125 

2. Isolation. — Exclusion of the patients from school and prevention 
of contact with non-immune persons. 

3. Concurrent disinfection of articles soiled by discharges from lesions. 

4. Terminal Disinfection. — Thorough cleaning. 



MEASLES. 

Measles (Rubeola).— An acute, highly infectious febrile disease, 
characterized by an initial coryza and a rapidly spreading skin eruption. 

Incidence. — Measles is a disease of childhood, but unprotected adults 
are liable to the infection. Although in itself a comparatively mild 
affection, measles, on account of its complications (especially pneu- 
monia) ranks as high as scarlet fever as a cause of death among infants 
and young -children. The disease is practically endemic in all large 
centers of population and is apt to be especially prevalent every other 
year. In more sparsely settled places it from time to time spreads and 
prevails epidemically. It occurs at all seasons, but prevails more 
extensively during the colder months. One attack usually confers 
immunity; but second, third or even fourth attacks are known. The 
close resemblance between German measles {rubella) and measles 
{rubeola) probably accounts for many so-called second attacks. 

Infectious Agent. — This is not positively known but is thought to be 
a filterable virus (found experimentally by Goldberger and Anderson 
in the blood of monkeys) . 

Source of Infection. — The virus of measles is contained in the buccal 
and nasal secretions of an infected individual. 

Mode of Transmission. — The infection is chiefly transmitted directly 
from person to person; also sometimes indirectly through articles 
freshly soiled with the buccal discharges of an infected individual. 
Measles is the most easily transmitted of the communicable diseases. 
The "scales" or desquamating epithelium have been shown, as the 
result of experiments, not to carry the infection; and so far as is known, 
the disease is not air-borne. 

Incubation Period. — This is long — from seven to eighteen days; 
usually about fourteen days. 

Period of Communicability. — The period of communicability begins 
with the prodromal catarrhal symptoms of the disease and continues 
until the cessation of abnormal mucous membrane secretions, the 
minimum being seven days, or from two days before to five days after 
the appearance of the rash. 

Methods of Control. — The control of measles is difficult, if not 
practically impossible, owing principally to two factors in the nature 
of the disease: (1) Because it is the most contagious of all the com- 
municable infections; and (2) because it is most readily communicable 
in the prodromal or pre-eruptive stage, and before the disease is 
recognizable. The slight danger of the average case prevents heroic 
measures being taken. 



126 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

But though comparatively little can be done to lessen the morbidity 
in measles, much can be done to decrease its mortality by delaying the 
age incidence until after the first five years of life, when the disease 
is most fatal, and by careful nursing and protection from the complica- 
tion and sequelae, more especially from pneumonia. 

The methods of control are as follows: 

1. The Infected Individual and his Environment. — 1. Recognition of the 
disease as soon as possible by the clinical symptoms, special attention 
being given to any rise of temperature, the Koplik spots, and the 
catarrhal symptoms in exposed individuals. 

2. Isolation during the period of communicability. 

3. Immunization. — None. 

4. Quarantine. — The exclusion of exposed susceptible children and 
teachers from school until eighteen days from the last possible exposure. 
This applies to exposure in the household, and exclusion* of exposed 
susceptible children — those not having had measles — from all public 
gatherings for the same period. 

5. Concurrent disinfection of all articles soiled with the secretions of 
the nose and throat. 

6. Terminal Disinfection. — Thorough cleansing, airing and sunning 
of the room occupied by the patient. Terminal fumigation is of little 
or no value in preventing the spread of measles, as the virus does 
not live long on fomites. There is practically no danger of children 
contracting the infection from the room in which the patient was 
treated, provided fourteen days have elapsed. But formaldehyde 
fumigation and disinfection may be practised, if desired, especially 
if healthy children are soon to occupy the room. 

II. General Measures. — 1. Daily examination of exposed children and 
of other possibly exposed persons. This examination should include a 
record of the bodily temperature. A non-immune person exhibiting 
a rise of temperature of 0.5° C. or more should be promptly isolated 
pending diagnosis. 

2. Where daily observation of the children by a doctor or nurse is 
available, the schools should not be closed or classes discontinued. 

3. Education of the public as to the special danger of exposing 
young children to those exhibiting acute catarrhal symptoms of any 
kind. 

GERMAN MEASLES. 

German Measles (Rubella, Rotheln), or Epidemic Roseola.— This 

eruptive infectious disease has also been known as hybrid measles and 
hybrid scarlet fever, because it presents features common to both. 
It is now regarded as a separate and distinct affection. 

Infectious Agent. — The infectious agent is unknown. 

Source of Infection. — The source of infection is the secretion of the 
mouth and possibly of the nose. 

Mode of Transmission. — The infection is propagated by direct contact 
with the patient or with articles freshly soiled with the discharges 



SCARLET FEVER 127 

from the throat or nose of the patient. It spreads with great rapidity, 
frequently attacking adults as well as children. The occurrence of 
either measles or scarlet fever in childhood is no protection against it. 
Epidemics of German measles are often very extensive. 

Incubation Period. — From ten to twenty-one days. 

Period of Communicability. — Presumably about eight days from the 
onset of the disease. 

Methods of Control. — German measles is usually a mild affection, 
altogether less serious than measles. The reason for attempting its 
control is that German measles may be confused with measles or 
scarlet fever, especially during its early stages. Each person having 
symptoms of the disease should therefore be placed under the care 
of a physician, and the case should be reported to the local health 
department. 

The measures of control to be instituted are as in measles. 

SCARLET FEVER. 

Scarlet Fever (Scarlatina).— An acute febrile, highly infectious dis- 
ease, characterized by a diffuse punctate erythematous skin eruption, 
accompanied by catarrhal, croupous or gangrenous inflammation of 
the upper respiratory tract and by manifestations of general systematic 
infection. 

Incidence. — The disease is very generally disseminated but is much 
more common in temperate climates than in the tropics. It occurs 
sporadically from time to time, and then under unknown conditions 
becomes widespread, the epidemics varying greatly in severity. 
Scarlet fever epidemics prevail at all seasons but perhaps with increased 
intensity in autumn and winter. 

Among predisposing factors age is most important, a large number 
of fatal cases occuring before the tenth year. Adults, however, are 
by no means exempt. Very young infants are rarely attacked. As in 
other infectious diseases, a certain number exposed to the infection 
escape; this susceptibility to the disease varying in individuals even of 
the same family. Males and females are equally affected. 

Infectious Agent. — This is unknown. By some the exciting factor is 
thought to be a streptococcus, but the evidence in favor of this view is 
very slight. 

Source of Infection. — The belief at present is that the virus of scarlet 
fever is contained in the secretions of the nose and throat, in the blood 
and in the lymph nodes, and that it is given off in the discharges from 
the mouth, the nose, the ears, and from broken-down glands of infected 
persons. 

Mode of Transmission. — The principal modes of transmission are: 
(1) Directly by personal contact with an infected person; (2) indirectly 
by articles freshly soiled with the discharges of an infected person. 
Carriers, and mild and unrecognized cases are doubtless frequent and 
play an important part in disseminating the disease, Foods may 



L28 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

also carry the infection. Milk-borne epidemics of scarlet fever have 
often been recorded. The " scaly" or desquamating epithelium, 
formerly thought to be infective, are no longer considered to convey 
the disease. 

Immunity. — One attack of scarlet fever ordinarily protects against 
subsequent attacks, but this immunity is not always permanent; 
second and even third attacks have been reported. 

Incubation Period. — Two to seven days; usually three or four days. 

Period of Communicability. — This may be stated to be about four 
weeks from the onset of the disease if abnormal discharges have ceased, 
and all open sores have healed. Patients without discharge may 
therefore be safely relieved after this period, even if desquamation is 
incomplete. When discharges persist from the ears, nose or tonsils 
cases may be infected for eight to ten weeks. 

Methods of Control. — Scarlet fever being a highly communicable 
disease, though somewhat less so than measles and smallpox, and 
often a very serious affection, the measures adopted for its control 
are necessarily in excess of the actual requirements. 

1. The Infected Individual and His Environment. — 1. Recognition of 
the disease by the clinical symptoms. 

2. Isolation. — Whether in the home or hospital strict isolation should 
be maintained in each case until the period of infectivity is passed, 
that is for a minimum period of four weeks, most cases require five 
weeks. The patient may be treated at home, provided suitable con- 
ditions, such as a room for isolation and a trained attendant, are 
obtainable; but preferably the patient should be sent to an isolation 
hospital. 

3. Immunization. — None. 

4. Quarantine in this disease requires the exclusion of all exposed 
susceptible children and teachers from school and food handlers from 
their work, until five days have elapsed since the last possible exposure 
to a recognized case. This includes all persons exposed, unless immun- 
ized by a previous attack of the disease. Other members of a house- 
hold, except food handlers, if the patient has been properly isolated, 
may be allowed to pursue their usual occupations. 

5. Concurrent disinfection of all articles which have been in contact 
with a patient, and all articles soiled with discharges of the patient. 
This includes thorough disinfection or boiling of bed and body linen, 
dishes, etc., used by the patient, and destruction by burning of all 
clothes contaminated by discharges, remnants of food, etc. The 
attending physician should wear a gown and disinfect his hands, and 
other exposed parts, thoroughly after each visit. The nurse should 
take the same precautions as in smallpox or any other highly infectious 
disease. Thermometers and other instruments used should receive 
special care and disinfection. 

6. Terminal Disinfection. — Thorough cleansing of all surfaces with 
good airing and sunning is sufficient; but formaldehyde fumigation 
may be practised if desired, and if the room is to be soon occupied. 






WHOOPING-COUGH 129 

II. General Measures. — 1. Daily examination of exposed children and 
other possibly exposed persons for a week after the last exposure. 

2. Where daily observation of the children by a doctor or nurse is 
available, the schools should not be closed. 

3. Education of the public as to the special danger of exposing 
young children to those exhibiting acute catarrhal symptoms of any 
kind. 

4. Pasteurization of the milk supply to guard against milk-borne 
scarlet fever. 

WHOOPING-COUGH. 

The infectious agent is the Bacillus pertussis of Bordet and Gengou. 
It is most abundant in the first days of the attack. After two weeks 
the bacilli are rarely obtained in cultures. They probably persist in 
some for considerably longer periods. The influenza bacilli are present 
in practically every case and add their influence. 

This disease occurs in epidemics, but sporadic cases appear in a 
community from time to time. Epidemics prevail for two or three 
months, usually during the winter and spring, often preceding or 
following measles. Children between the first and second dentition 
are commonly affected. Adults and old people are sometimes attacked, 
and in the aged it may be a very serious affection. Whooping-cough 
is a dangerous disease because of the complications and sequelse. 
Of these the most important are the pulmonary complications, such 
as bronchopneumonia, pneumothorax and tuberculosis. The very 
young infant is immune usually because of the transfer of passive 
immunity from the mother; but what was thought to be whooping- 
cough was probably distemper. One attack confers a definite and 
prolonged immunity but this disappears entirely in some after the 
lapse of years. Domestic animals (dogs and cats) may possibly be 
affected by whooping-cough, and transmit the disease. 

Source of Infection. — The source of infection is the discharges from 
the laryngeal and bronchial mucous membranes of infected persons 
(sometimes also of infected dogs and cats). 

Mode of Transmission. — The mode of transmission is by contact 
with an infected person or animal or w T ith articles freshly soiled with 
the respiratory discharges of such person. 

Incubation Period. — The incubation period is within fourteen days. 

Period of Communicability. — The disease is particularly communicable 
in the early catarrhal stages before the characteristic whoop makes 
the clinical diagnosis possible. Communicability probably persists in 
other than carrier cases not longer than two weeks after the develop- 
ment of the characteristic whoop. 

Methods of Control. — I. The Infected Individual and His Environ- 
ment. — 1. Recognition of the disease from the clinical symptoms sup- 
ported by a differential leukocyte count, and confirmed when possible 
by a competent bacteriological examination of the bronchial secretions. 
9 



130 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

2. Isolation. — Separation of the patients from susceptible children 
and exclusion of the patient from schools and public places for the 
period of presumed infectivity. 

3. Immunization. — The use of prophylactic vaccines gives a moder- 
ate proportion of the treated protection. This does not develop till 
after ten days to three weeks. 

4. Quarantine. — Limited to the exclusion of non-immune children 
from school and public places for fourteen days after their last exposure 
to a recognized case. 

5. Concurrent disinfection of discharges from the nose and throat 
of the patients and articles soiled therewith. 

6. Terminal Disinfection. — Cleansing of the premises used by the 
patients. 

n. General Measures. — Education of the public in habits of personal 
cleanliness and in the dangers of association or contact with those 
showing catarrhal symptoms with cough. 

MUMPS. 

Mumps (Epidemic Parotitis). — An infectious disease, characterized 
by inflammation of the parotid gland. 

Mumps is probably endemic in large centers of population, occuring 
particularly in the spring and winter months. It is met with most 
commonly in childhood and adolescents. Very young infants and 
adults are rarely attacked. Males are somewhat more frequently 
affected than females in epidemics. The testes in males and the 
ovaries and breasts in females are sometimes involved, occasionally 
resulting in sterility. One attack usually confers immunity. 

Infectious Agent. — The infectious agent is unknown. 

Source of Infection. — The source of infection is the secretions of the 
mouth and possibly of the nose. 

Mode of Transmission.— The mode of transmission is by direct contact 
with an infected person or with articles freshly soiled with the dis- 
charges from the throat and nose ot such infected persons. 

Incubation Period. — The incubation period is from four to twenty- 
five days; the average period is about fourteen days. 

Period of Communicability. — The period of communicability is un- 
known but presumably until the parotid gland has returned to its 
normal size. 

Methods of Control. — I. The Infected Individual and His Environ- 
ment. — 1. Recognition of the disease by its clinical symptoms. The 
inflammation of Steno's duct may be of assistance in recognizing the 
early stage of the disease. The diagnosis is usually made in the swelling 
of the parotid gland. 

2. Isolation. — Separation of the patients from non-immune children 
and the exclusion of such patient from school and public places for the 
period of presumed communicability. 

3, Immunization, — None* 









TYPHOID FEVER 131 

4. Quarantine. — Limited to exclusion of non-immune children from 
school and public gatherings for fourteen days after the last exposure 
to a recognized case. 

5. Concurrent disinfection of all articles soiled with the discharges 
from the throat and nose of the patients. 

6. Terminal Disinfection. — None. 
n. General Measures. — None. 

TYPHOID FEVER. 

Infective Agent. — The infective agent is the Bacillus typhosus or 
typhoid bacillus, which is constantly present in the pathological lesions 
of the disease. It probably always enters the body by way of the 
mouth, passes to the intestinal tract, penetrates the mucous membranes, 
and then invades the system. The bacillus leaves the body chiefly in 
the alvine discharges less often in the urine, and occasionally in other 
discharges. Healthy carriers of the infective agent are common. 

Incidence. — The disease is most prevalent in the late siunmer and 
autumn months; but serious outbreaks may occur at any season of the 
year. It occurs both in endemic and epidemic forms. Endemic 
typhoid, or that which is constantly present, is sometimes spoken of as 
residual typhoid, a term applied to the unexplained typhoid fever which 
is still remaining in a community after the water supply has been 
purified, and in which all known sources of the disease have been 
eliminated. The disease is more prevalent in country districts than 
in cities, particularly in the southern States, probably owing to insani- 
tary rural conditions. 

Typhoid fever attacks individuals, as a rule, in the period of their 
greatest usefulness and value, that is between the ages of fifteen 
and thirty, thereby causing an enormous economic loss. It is not 
infrequent in childhood, but cases over sixty years of age are rare. 
As in other infectious diseases, not every one exposed to the infection 
is equally susceptible. It is now known that the bacilli do not multiply 
in water. Many survive only a few hours and a minute percentage 
remain alive in water more than seven days. In water that is polluted 
while more apt to be present, they disappear more rapidly, and more 
rapidly in the warm water of siunmer than in the cold water of winter. 

Water-borne epidemics are recognized to have certain characteristics 
as follows: 

1. They occur somewhat more frequently in spring, fall or whiter, 
when the water is cold and freshets are apt to wash infection from its 
sources and convey it rapidly to the consumer. 

2. They usually have a sudden onset, the number of cases rising to 
a peak and then declining rapidly. 

3 The pollution is usually nearby, indicating the direct transmission 
of fresh, virulent infection. 

Ice, exceptionally, may transmit typhoid bacilli. The total number 
of instances, however, of typhoid fever which have been directly 



L32 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

traced to ice infection are exceedingly few. Freezing itself does not 
kill more than 50 per cent, of typhoid bacilli, but in freezing many are 
eliminated and those that remain rather quickly die. This fact makes 
it possible to conceive that ice from moderately infected water may 
contain a few living typhoid bacilli, but these are so few in number that 
only the exceptional person here and there becomes infected, and thus 
the source of the infection remains undetected. Although freezing 
does not kill all the bacilli, there is a great reduction in their number 
not only from the act of freezing, but also during storage. The danger 
from the use of ice produced from polluted water is, therefore, much 
less than from the use of the water itself. Every week that the ice 
is stored this danger becomes less, so that at the end of four weeks it 
has becomes as much purified from typhoid bacilli as if subjected to 
sand filtration. At the end of four months the danger becomes almost 
negligible, and at the end of six months quite so. These facts assure 
us that natural ice which is stored usually for several weeks or months 
before it is used, is practically safe. There is no appreciable increase 
in the amount of typhoid fever in New York City in the spring when 
the new crop of Hudson River ice is used. The water from which the 
ice is taken is moderately infected. Manufactured ice made from 
distilled water and carefully handled is absolutely pure. 

Milk is frequently a serious source of infection. The typhoid 
bacillus grows well in milk. Many epidemics of typhoid fever have 
until recently puzzled sanitarians because, though evidently milk- 
borne, yet no case of typhoid fever could be found. The discovery 
that about 2 per cent, of those who have recovered from typhoid fever 
remain infected, and continue for varying periods and even during the 
rest of their lives to pass typhoid bacilli, has cleared up the mystery. 
Persons who have never had typhoid fever may occasionally become 
carriers. Over four hundred cases of the disease were traced several 
years ago in New York City to the infection of a milk supply by a 
typhoid carrier who had the disease forty-seven years before. In a 
four years' study of typhoid fever in Washington, it was found that at 
least 10 per cent, of the cases were apparently milk-borne. 

Hands, water, flies, etc., may all aid in the transfer of the bacilli 
from the infected dejecta to the milk. The milk may become con- 
taminated on the farm, in transportation, at the city dairy or at the 
home. 

Milk-borne epidemics have the following characteristics: 

1. They curve abruptly, rise to a peak and subside rather sharply 
like water-borne epidemics, but they occur at any time of the year. 

2. The cases occur on the track of a milk supply, and are mostly 
confined to that area. 

3. The cases are found chiefly among those who are large consumers 
of milk. 

4. More than one case is apt to occur at the same time in a family. 

5. The disease shows a shorter incubation period, probably due to 
the greater amount of infection taken. 



TYPHOID FEVER 133 

Unpasteurized milk products, such as cream, ice-cream, butter and 
buttermilk, and fresh cheese, may contain typhoid bacilli, and thus 
occasionally become a means of transmitting the infection. 

In the same way other food products may become infected. 

Raw oysters, clams, mussels and other shell fish grown in polluted 
waters, or any food contaminated by infected hands, flies, etc., may 
be an occasional mode of transmitting the disease. Several small 
epidemics, both in this country and in Europe, have been traced to 
eating raw oysters and other shell fish. 

Fruits and Vegetables. — Such vegetables as celery, lettuce, radishes 
and watercress, which are taken raw and grown on land fertilized with 
fresh night soil, may become a means of transmitting the disease 
at times. Fruit and vegetables handled by a typhoid carrier may also 
become contaminated. Epidemics have been traced to these sources. 

Flies. — The common house-fly and other insects, acting as mechanical 
carriers of the bacilli, may undoubtedly convey the infection from 
exposed typhoid discharges to food and the surfaces of things upon 
which they light. The danger from this source is now well recognized, 
though it has been probably exaggerated. Nevertheless, this danger 
is sufficient everywhere and especially among unsanitary surroundings 
to necessitate the proper screening and protection from flies, and the 
extermination of these and other insects as far as possible, by destruc- 
tion of their breeding places. 

Fomites. — Any objects which may have become soiled and con- 
taminated by contact with the discharges of a typhoid patient, such as 
bed linens, blankets, and the like, may convey the infection. 

Dust. — In dust the bacilli soon die, especially when exposed to the 
sun and air. Dust-borne infection in this disease, though conceivably 
possible, must be very exceptional. 

Soil. — Formerly the soil was thought to be a most important factor 
in the production of the disease, and by Pettenkofer and others it was 
regarded as essential. But we now know that the condition of the soil 
does not affect the disease, other than that its pollution may endanger 
the contamination of drinking water, milk and other foods, or become 
a means of infection through flies, etc. In this respect the condition 
of the soil is of the greatest importance. 

Typhoid Carriers. — Another important mode of transmission of 
infection in this disease, which is comparatively common, is by means 
of so-called typhoid carriers. Examinations of convalescent typhoid 
cases show that about 1 per cent, continue to pass typhoid bacilli for 
years, perhaps for life. Some of these bacilli carriers do not know 
either that they had typhoid fever or were in contact with it. In 
Washington typhoid bacilli were isolated from the stools of a number 
of healthy persons (0.3 per cent, of the number examined) with no 
known exposure. These not only had not had typhoid fever but had 
not been in contact with those having it. 

These cases may be called "healthy or normal carriers" in contra- 
distinction to "convalescent carriers," or those who harbor the bacilli 



134 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

during convalescence only. In our laboratory we have found in a 
State institution for the insane six carriers in one hundred and forty 
convalescents, or about 4 per cent. The focus of infection is either 
the gall-bladder or gall-ducts. The majority of cases are women. 

A remarkable case of a healthy carrier has been under our care for 
many years. Though well known from its publication in other places, 
it is of sufficient interest to repeat again here. 

This was the case of a cook, who in 1901 was employed in a family, 
where ten days after entering the household a visitor developed typhoid 
fever. The cook had then been with the family three years, so at that 
time there was no reason to suspect the cook. She took a place in 
another family, and one month later the laundress in this family con- 
tracted typhoid fever. In 1902 the cook obtained a new position. 
Two weeks after her arrival, the laundress here was taken ill; in a week 
a second case developed, and soon seven members of the household were 
sick. In 1904 the cook went to a home in Long Island. There were 
four in the family as well as seven servants. Within three weeks after 
her arrival, four servants were attacked. In 1906 the cook went to 
another family. Between August 27 and September 3, six out of its 
eleven inmates were attacked with typhoid fever. Then for the first 
time suspicion was directed to the cook. She entered another family 
on September 21. On October 5, the laundress developed typhoid 
fever, and two months after her arrival 2 cases developed, one of which 
proved fatal. Altogether during five years this cook is known to have 
been the cause of 26 cases of typhoid fever. 

On March 19, 1907, the cook was removed to the hospital. Cultures 
were taken every few days and showed bacilli off and on for three years. 
Sometimes the stools contained enormous numbers of typhoid bacilli, 
and again for days none would be found. After a detention of three 
years she was discharged after having promised not to cook. Two 
years later she broke the promise. Typhoid fever developed in two 
families and thus having become a cook in New York Hospital she was 
the cause of an outbreak in which some thirty-one doctors and nurses 
were attacked. This brought about her detection and second isolation 
at Riverside Hospital. 

As already mentioned, we recently traced some hundreds of cases of 
typhoid fever to a milk supply produced at a farm looked after by a 
typhoid carrier who had typhoid fever forty-seven years previously. 

The menace of these healthy carriers, especially in handling food- 
stuffs as in the case of a cook or waitress or in a dairy, in the trans- 
mission of typhoid fever, is self-evident. So far most of the outbreaks 
of the disease that have been traced have been due to carriers who 
discharge the bacilli in their feces rather than in their urine. 

Diagnosis. — The diagnosis of typhoid fever is made by recognition 
of the clinical symptoms, the specific agglutination test and the bac- 
teriological examination of the blood, bowel discharges or urine. Early 
diagnosis is important not only for the successful treatment of the dis- 
ease, but for the control of the spread of the infection. This can only 



'TYPHOID FEVER l3o 

be assured through laboratory methods which should be entrusted not 
to casual examiners but to experts. (For description of these methods, 
see "Pathogenic Microorganisms" by Park and Williams.) 

The Gruber-W idal or Agglutination Test has been used for the routine 
examination of the blood-serum of suspected cases of typhoid fever 
since 1896, and proved to be of great assistance in the diagnosis of 
obscure cases of the disease. 

Dried blood is ordinarily used for the application of the test. 

Serum can be more accurately diluted and measured for the test 
than the dried blood, and for scientific investigations and for accurate 
results, especially in obscure cases and in those who have had the 
vaccine, when repeated tests may be required, it is to be preferred. 
Practically, however, the results are nearly as good for diagnostic 
purposes from the dried blood as from the serum, and the dried blood 
is more easily obtained and shipped. 

It has been found that about 20 per cent, give positive results in the 
first week, about 60 per cent, in the second week, about 80 per cent, in 
the third week, and about 90 per cent, in the fourth week. In 98 per 
cent, of the cases in which repeated examinations were made, a reaction 
was present at some time during the illness. 

Bacteriological Examination of the Blood. — This is the best method 
for early diagnosis, a blood culture being usually positive during the 
first week of typhoid fever. The bacilli may appear in the blood even 
in the first few days. They then lessen proportionately imtil the end of 
the disease. In relapses they reappear. 

Examination of Feces and Urine. — The feces are collected in rectal 
tubes or glass vials. The more promptly the stools are examined after 
passage, the better is the chance of isolating the typhoid bacilli. Indeed, 
unless the specimen is sent to the laboratory immediately, it is practi- 
cally useless to make the examination. 

Typhoid bacilli are found in the feces upon examination often as 
early as the sixth or seventh day, and from then on until convalescence. 
In about 25 per cent, of all cases they may be obtained in the first 
examination, from the seventh to the twenty-first day of the disease, 
and in about 75 per cent, after repeated examinations. The short life 
of the typhoid bacillus in many specimens of feces suggests that stools 
should be examined as quickly as possible after passage. 

Of great interest also is the frequent occurrence of typhoid bacilli 
in large numbers in the urine. They are not apt to be found in the 
urine until the end of the second week of the fever, and may not appear 
until much later. From this on to convalescence they appear in from 
25 to 50 per cent, of all cases, usually hi pine culture and in enormous 
numbers. They are found until several weeks or months after convales- 
cence; in exceptional cases they may be present for years. 

When we think of the chances such cases have to spread infection 
as they pass from place to place, we begin to realize how epidemics can 
start without apparent cause. The disinfection of the feces and urine 
should, therefore, be specially looked after in typhoid fever, and con- 






136 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

valescents should not be allowed to go to places where contamination 
of the water supply is possible, without at least warning them of the 
necessity of great care in disinfecting their own feces and urine for 
some weeks. 

Incubation Period. — The incubation period in typhoid fever is from 
seven to twenty-three days; average ten to fourteen days. 

Period of Communicability. — This begins with the appearance of the 
prodromal symptoms of the disease, and continues throughout the 
illness and relapses, during convalescence, and does not cease until 
repeated examinations of the discharges show persistent absence of the 
infecting organism. 

Immunity. — After recovery from typhoid a considerable natural 
immunity is present which lasts for years. This is not absolute, as 
about 2 per cent, of those having typhoid fever have a second attack 
which is usually a mild one. 

Preventive Immunization or Vaccination. — An active immunity to 
typhoid fever may be artificially induced by injecting killed typhoid 
bacilli into the subcutaneous tissues. This so-called " vaccination' ' 
against typhoid fever is now a procedure of established worth — rational, 
harmless and effective. 

Its use began in 1896 with Pfeiffer and Kolle and Wright independ- 
ently. Wright then introduced the method in the English army, and 
the results led to its adoption in other countries. Vaccination against 
typhoid fever was started in the American army in 1899 under the 
supervision of Russell. 

Three doses of the vaccine are usually administered when salt solu- 
tion suspensions are used, the site of the inoculation being the subcu- 
taneous tissues over the insertion of the deltoid. The first dose is 
500,000,000, the second and third doses 1,000,000,000 each, typhoid 
bacilli. The period between the inoculations is seven to ten days, the 
injection being given late in the afternoon, so that if a reaction occurs 
the person will be in bed. The reaction usually consists of a reddening 
and swelling at the point of inoculation, which is tender. In some 
instances this area is larger, and the axillary lymph nodes become 
swollen and sore. A general reaction is usually absent, or if present 
consists of slight malaise. In a few cases, less than 1 per cent., a more 
marked reaction occurs with prostration and considerable rise of 
temperature. The reaction is of no importance farther than the dis- 
comfort caused. 

The vaccine usually employed is a suspension of the bacilli grown on 
agar, standardized by the method of Wright and killed by heating to 
56° C. Sensitized vaccines of either killed or live bacilli have also 
been used, but they have not been generally adopted. 

During the war the army has used a suspension in cottonseed-oil. 
The three full doses are given in one injection. The oil prevents the 
rapid absorption and to some degree interferes with the immunity 
response. 

The immunity produced varies both in degree and in duration. The 



TYPHOID FEVER 137 

protection conferred is only relative, and with an undue amount of 
exposure infection may result. The duration of the immunity is at 
least one year, but it may last three or four years; the average being 
about two and a half years. 

The results of typhoid inoculations can no longer be questioned. 
The most striking effects have been the reduction of the death-rate in 
those persons who have been properly vaccinated against the disease. 
The best results have been obtained in the armies of Europe and the 
United States. The French army was only about one-third vaccinated 
when war broke out. In consequence typhoid and paratyphoid fevers 
were abundant to such an extent that hundreds of cases developed daily. 
Within a year all were inoculated with the typhoid vaccine and the cases 
of fever diminished 90 per cent. Within the next year all had received 
paratyphoid A. and B. inoculations and the fevers diminished to 1 per 
cent, of the original amount. In the American army cases of typhoid 
fever were very few during the first year, but fairly frequent in the last 
half year of the war. Thus in July, 1918, a replacement unit consisting of 
248 men going from Texas to England developed a number of cases, so 
that in all 39 per cent, were attacked with a mortality of 8.4 per cent. 
These men drank badly contaminated water. During the Chateau- 
Thierry offensive diarrheal diseases were very prevalent, approximately 
75 per cent, were attacked. The prevailing diseases were simple diar- 
rhea, bacillary dysentery, typhoid fever and the A and B types of para- 
typhoid fever. These conditions were met with at other portions of the 
front. It is evident that typhoid vaccine, although it gives a marked 
degree of immunity, cannot be wholly depended on when great ex- 
posure to infection is combined with great bodily strain. The inocula- 
tion being accompanied by no danger, the method is especially applicable 
to those unduly exposed to infection from typhoid fever, such as nurses, 
hospital attendants, physicians, travellers, soldiers in camps, persons in 
epidemic localities, and persons m the family of a bacillus carrier. 

Methods of Control. — These may be divided into measures affecting 
the infected individual and his immediate environment; and general 
measures. 

1. The Infected Individual and his Environment.- — 1. Success in the 
control as well as the treatment of typhoid fever depends upon early 
recognition of the disease by its clinical symptoms, confirmed by 
specific tests, the Widal or agglutination reaction and bacteriological 
examination of the blood, feces or urine. 

2. Isolation in a fly-proof room, preferably under hospital condi- 
tions, of such cases as cannot command adequate sanitary environ- 
ment and nursing care in their homes. 

3. Immunization or preventive inoculation of all susceptibles who 
are known to have been exposed, or are suspected of having been 
exposed to the infection. This immunization is only relative and in 
no way does away with the need of precautions to prevent infection 
through water, milk, hands, etc. 

4. Quarantine. — None. 



, 



13S PREYEXTION OF INDIVIDUAL INFECTIOUS DISEASES 

5. Concurrent Disinfection.— The disinfection of all bowel and 
urinary discharges and articles soiled with them. For the urine 
bichloride of mercury (1 to 1000) or carbolic acid (2.5 per cent.) or 
formalin (10 per cent.) may be used and allowed to stand one hour. 
For the stools bleaching powder (3 per cent.), unslaked lime and hot 
water, carbolic acid (5 per cent.), or formalin (10 per cent.) are efficient. 
The disinfectants must be added in sufficient quantity and be left 
long enough in contact with the feces to thoroughly penetrate them. 
To disintegrate the feces, it may be necessary to break them up by 
stirring. The stronger disinfectants should be allowed to stand for 
at least one hour; carbolic acid requires twelve hours or more. The 
sputum and other discharges may be burned or scalded. Strong car- 
bolic acid, cresol or formalin may also be used. 

The patient should use his own special eating utensils, which should 
be scalded after use. All remnants of food should be burned or boiled 
before discarding. Attendants and nurses should be careful not only 
to avoid infecting themselves by constant washing of the hands in 
bichloride solution, but they should prevent the infection of others 
by keeping out of the kitchen, ice-box, etc., in private homes, unless 
there is a special diet kitchen for the patient. 

Bedding, sheets, night wear, and all fabrics that may have come in 
contact with the patient or his discharges should be disinfected by 
boiling or immersion for one hour in bichloride of mercury solution 
(1 to 1000), carbolic acid (2.5 per cent.) or cresol. Thermometers 
should be kept in formalin, alcohol or other germicidal solution. Bed- 
pans, which should be of glass or earthenware, must always contain 
some liquid disinfectant. 

6. Terminal Disinfection. — At the conclusion of the cases a general 
disinfection and cleansing of the room and its contents should be 
carried out. 

n. General Measures. — These may be summarized as follows: 

1. Purification of public water supplies. 

2. Pasteurization of public milk supplies. 

3. Supervision of other food supplies, and of food handlers. 

4. Prevention of fly-breeding. 

5. Sanitary disposal of human excreta. 

6. Extension of immunization by vaccination as far as practicable. 

7. Supervision of typhoid carriers and their exclusion from the hand- 
ling of foods. 

8. Systematic examination of fecal specimens from those who have 
been in contact with recognized cases to detect carriers. 

9. Exclusion of suspected milk supplies pending discovery of the 
person or other cause of contamination of the milk. 

10. Inclusion of water supply, if contaminated until adequately 
treated with hypochlorite or other efficient disinfectant, or unless all 
water used for toilet, cooking and drinking purposes, is boiled before 
use. 

If these measures, personal and general, for the control of typhoid 



DYSENTERY 139 

fever were consistently and conscientiously carried out, which depends 
to a large extent upon the cooperation and encouragement of local 
health officers, the prevalence of this disease in the United States, 
where it exists to an unwarrantable degree, would undoubtedly be 
greatly reduced. 

PARATYPHOID FEVER. 

Paratyphoid fever is clinically and etiologically similar to typhoid 
fever, from which disease it is often indistinguishable except by careful 
bacteriological examination. 

Epidemiologically the two diseases are very similar. Paratyphoid 
is a world-wide infection, but it prevails less commonly than typhoid 
and though outbreaks occur of considerable extent, it never causes such 
fatal epidemics of the disease, as are often observed in water-borne or 
milk-borne typhoid. 

Although the symptoms of the two diseases are somewhat similar, 
paratyphoid fever usually runs a milder course. The degree of immu- 
nity conferred by an attack of paratyphoid is probably marked; an 
attack of paratyphoid does not protect against typhoid, nor vice versa. 

Infecting Agent. — The infecting agent is the bacillus paratyphosus 
A or B, belonging to a group of bacilli closely resembling the typhoid 
bacillus. A fundamental mark of differentiation between them is 
that each leave specific agglutination properties. The bacilli are 
usually present in the feces, urine, blood and bile of infected persons 
early in the disease, and often during the whole course. 

Source of Infection. — The source of infection is the bowel discharges 
and urine of infected persons and foods contaminated with such dis- 
charges of infected persons or of healthy carriers. Healthy carriers may 
be numerous in an outbreak. 

Period of Communicability. — The period of communicability is like 
that of typhoid fever, from the appearance of prodromal symptoms 
throughout the illness and relapses, during convalescence, and until 
repeated bacteriological examinations of the discharges show absence 
of the infecting organism. 

Methods of control are similar to those used in typhoid fever. 

DYSENTERY. 

Dysentery may be divided into acute and chronic or bacillary and 
amebic dysentery. 

A. Bacillary Dysentery. — This disease is distributed over the whole 
world. This is the form of dysentery that prevails in ships, camps 
jails, etc. The usual summer diarrheas of children are not bacillary 
dysentery, but are due mostly to improper feeding or clothing or 
unhygienic practices. They are largely communicable, however, and 
for this reason they should be made reportable and treated as infectious 
diseases so as not to transmit slightly pathogenic streptococci and colon 
bacilli. 



140 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

Infective Agent. — The infective agent is the bacillus dysenteriae of 
Shiga or other allied strains, which develop only in the intestines. 

Source of Infection. — The source of infection is the bowel discharges 
of infected persons. 

Mode of Transmission. — The mode of transmission is by drinking 
contaminated water, and by eating infected foods, and by hand-to- 
mouth transfer of infected material, also from formitus or objects 
soiled with discharges of an infected individual or a carrier. Flies, 
vermin, etc., may act as mechanical carriers of infection. 

Incubation Period. — The incubation period is from two to seven days. 

Period of Communicability. — The period of communicability is during 
the febrile period of the disease and until the organism is absent from 
the bowel discharges. 

Methods of Control. — 1. Recognition of the disease by the clinical 
symptoms, confirmed by serological (agglutination) and bacteriological 
tests. 

2. Isolation of infected individuals during the communicable period 
of infection. 

3. Immunization. — -Vaccines give considerable immunity, but owing 
to the severe reactions produced their use is not general, nor should 
they be made compulsory except under extreme emergency. Immune 
sera have been used with apparently good results when employed early 
in the disease. A polyvalent serum should be used until the strain 
type is identified. 

General Measures. — 1. Reject personal prophylaxis of attendants upon 
infected persons. 

2. No milk or food for human consumption should be sold from a 
place occupied by a patient unless the persons engaged therein occupy 
quarters separate from the house where the patient is sick, and all 
utensils used are cleansed and kept in a separate building, and under a 
permit from the health officer. 

3. All attendants upon persons affected with this disease should be 
prohibited from having anything to do with the handling of food. 

4. Necessary precautions should be taken against flies. 

B. Amebic Dysentery. — Amebic dysentery (amebic colitis or enteritis) 
is a chronic infection, commencing insidiously, and characterized by 
relapses and recurrences. It is frequently associated with sequelae, 
such as abscesses of the liver. The disease occurs sporadically or in 
endemic foci, mainly in the tropics. There are no epidemics of amebic 
dysentery. It is particularly prevalent in Egypt, India and the Philip- 
pine Islands, but occurs also in parts of South America and the Southern 
United States. A few cases have been reported in the Northern United 
States and in Europe. Where it is endemic, the largest number of cases 
occur after the heavy rains have set in during early summer. Males 
are more frequently attacked than females, probably because more 
exposed to infection. It may occur at all ages, but young adults seem 
most susceptible. The foreign white race appear to be less resistant 
to infection than the natives. 



CHOLERA 141 

Infective Agent. — The infective agent is the ameba or entameba 
histolytica. 

Source of Infection. — The source of infection is the bowel discharges 
of infected persons. 

Mode of Transmission. — The mode of transmission is by drinking 
contaminated water and by eating infected foods, and by hand-to- 
mouth transfer of infected material; from objects soiled with discharges 
of an infected individual, or of a carrier; and by flies, etc. Unhygienic 
surroundings are generally a predisposing factor, but in the Philippines 
individuals of all classes are likely to be attacked who do not take 
continuous and extra precautions regarding their drinking water. 

Incubation Period. — The incubation period is unknown. 

Period of Communicability. — The period of communicability is during 
the course of the disease and until repeated microscopic examinations 
of the stools show absence of the ameba histolytica. 

Method of Control.— I. The Infected Individual and his Environ- 
ment. — 1 . Recognition of the disease by the clinical symptoms, confirmed 
by microscopic examination of the stools, to be made as soon as possible 
after they are passed. 

2. Immunization. — None. 

3. Concurrent disinfection of the bowel discharges as in typhoid 
fever. 

n. General Measures. — 1. Boil all drinking water unless the supply 
is known to be free from contamination. 

2. The water supply should be protected against contamination, 
and supervision should be exercised over all foods eaten raw. 

Ipecac or its alkaloid emetin has been found to be practically a 
specific curative treatment when the ameba are in the vegetative stage, 
but it does affect the cysts. 

Differential Diagnosis Between Amebic and Bacillary Dysentery. — 
In amebic dysentery: (1) the disease is usually chronic; (2) the ameba 
histolytica are usually found in the feces; (3) no severe toxic symp- 
toms are present; (4) abscess of the liver is a frequent sequela; (5) the 
lesions are found in the cecum and descending colon, not in the small 
intestine. In bacillary dysentery, the finding of the bacilli, and a 
positive agglutination test, together with the clinical symptoms of 
intoxications make a certain diagnosis. Both infections may exist at 
the same time. 

CHOLERA. 

Infective Agent. — The infective agent is the vibrio cholera? or 
"Comma bacillus" of Koch. It is found only in the intestines, not in 
the blood or internal organs of infected persons. 

There is scarcely any country in the world that has not been visited 
at some time or other by this fatal affection. The last severe epidemic 
in Europe was that of Hamburg, Germany, in 1892, when the disease 
threatened to become pandemic. A few cases, following the routes 
of trade were brought to New York by the transatlantic liners, but 



142 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

aggressive preventive measures soon checked the spread of the infec- 
tion. Cholera has prevailed for years in the Philippines, but is now 
under control. 

Source of Infection. — The source of infection is the bowel discharges 
and vomitus of infected individuals, and the feces of convalescents or 
healthy carriers. These carriers are very common; 10 per cent, of 
contacts may be found to be carriers. The carriers' condition lasts only 
a few days or weeks. 

Mode of Transmission. — The mode of transmission is by food and 
water polluted by the infective agent, by contact with infected persons, 
carriers or articles freshly soiled by their discharges, and by flies. 

The two fundamental facts 4n the transmission of infection are that 
the vibrios leave the body only in the feces, and that the mode of infec- 
tion is by way of the mouth. The feces of the cholera patient during 
the acute stage of the disease are extremely rich in vibrios, which are at 
present in almost pure cultures. As the case recovers they decrease in 
number, but persist after recovery for a short time. That is, chronic 
carriers do not exist. These persons constitute the "convalescent 
carriers." Mild cases which are undiagnosed or overlooked may thus 
become a source of danger. Another group of persons may act as 
sources of infection; these are the "healthy carriers" who excrete 
cholera vibrios in their stools. Not all persons who ingest cholera 
develop the disease. In a number of these, the vibrio will multiply 
in the intestine to a limited extent and be excreted in the stools, 
although no clinical evidences of the disease are present. Such healthy 
carriers are important not only as insidious spreaders of infection, but 
they may be potential cases of cholera, should their resistance be 
lowered. 

The susceptibility to infection of different individuals varies and 
conditions may lower or. raise the resistance of the individual. The 
resistance depends partly on antibodies and partly on the health of the 
person. Gastric and intestinal disorders due to indiscreet eating and 
drinking, or other causes, undoubtedly favor infection, or in the case 
of healthy carriers may cause the development of cholera. 

Incubation Period. — The incubation period of the disease is from one 
to five, usually three days, occasionally longer if the healthy carrier 
stage, before development of symptoms is included. 

Period of Communicability. — The period of communicability is usually 
seven to fourteen days and occasionally longer. 

Methods of Control. — I. The Infected Individual and his Environ- 
ment. — 1. Recognition of the disease by the clinical symptoms confirmed 
by bacteriological examination, viz., isolation and identification of the 
cholera vibrio in pure culture. A presumptive diagnosis of cholera 
may be made by finding large numbers of comma-shaped bacilli in 
direct microscopic examination of stained preparations or in hanging 
drops of the mucous flakes found in cholera stools. But this is only 
presumptive and cannot be dependent upon. The only positive 
diagnosis consists in the biological reactions of the microorganisms 



CHOLERA 143 

obtained in pure culture, the most reliable tests being the agglutination 
test with a known serum. 

2. Isolation of the patient in a special hospital or screened room with 
trained attendant. 

3. Immunization. — A vaccine similar to the typhoid vaccine was 
suggested by Haffkine. The use of the vaccine gives a considerable 
degree of immunity. In those who have been attacked the mortality 
of the disease has been reduced, viz., from 75 per cent, among the 
un vaccinated to 42 per cent, among the vaccinated. The duration of 
mmunity is about a year. 

4. Quarantine is justified for the prevention of this disease. All 
contacts, or persons who have been exposed to infection, should be 
quarantined for five days from the last exposure. 

5. Concurrent Disinfection. — This includes prompt and thorough 
disinfection of the stools and vomited matter by formalin (10 per cent.), 
carbolic acid (5 per cent.), milk of lime (1 to 8) or chlorinated lime 
(3 per cent.) All articles used by and in connection with the patient 
must be disinfected before removal from the room. Remnants of 
food left by the patient must be burned. 

6. Terminal Disinfection. — The bodies of those dying from cholera 
should be cremated if practicable, or otherwise wrapped in a sheet wet 
with a disinfectant solution and placed in water-tight casks. The room 
in which a sick person was isolated should be thoroughly cleansed by 
washing the surfaces with bichloride solution or creosote preparation 
and disinfected by treatment with formaldehyde gas. 

n. General Measures. — 1. Rigid personal prophylaxis of attendants 
by scrupulous cleanliness, disinfection of hands each time after handling 
the patient or touching articles contaminated by dejecta, the avoidance 
of eating or drinking anything in the room of the patient and the 
prohibition of those attendant on the sick from entering the kitchen. 

2. Bacteriological examination of the stools of all contacts to deter- 
mine carriers; and isolation of carriers. 

3. Water should be boiled if used for drinking or toilet purposes, or 
if used in washing dishes or food containers unless the water supply is 
adequately protected against contamination or is so treated, as by 
chlorination, that the cholera vibrio cannot survive in it. 

4. Careful supervision of food and drink. Where cholera is prevalent 
only cooked food should be used. Food and drink after cooking or 
boiling should be protected against contamination, as by flies and 
human handling. 

HI. Epidemic Measures. — Inspection service with laboratory for early 
detection and isolation of cases; examination of persons exposed in 
infected centers for detection of carriers, and the isolation or control 
of carriers; disinfection of rooms occupied by the sick; and the deten- 
tion in suitable camps and barracks for five days, of those desirous of 
leaving for another locality. Those so detained should be examined 
for the detection of carriers. 



144 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 



THE VENEREAL DISEASES. 

In their effects on the individual, on the State and on posterity, 
there is no other single disease or group of diseases which compares 
with syphilis and gonorrhea. The effects of these diseases on the indi- 
vidual are those due to the loss of efficiency and earning capacity. 
This loss in the population at large cannot be accurately determined, 
as no records have been kept of cases and deaths; so that the effects 
in civil life as a whole can only be approximated. There are, however, 
definite figures at hand for selected groups. 

Recent reports from the Surgeon General of the Army state that no 
disclosures during the late war were more startling than those showing 
the destructive inroads of the venereal diseases on the health and 
efficiency of the soldiers and this was in spite of the greatest efforts 
put forth to prevent infection. From the time the United States 
entered the war in April, 1917 to September, 1918 the loss to the army 
from venereal diseases represented 2,295,000 days of service, and the 
venereal diseases in the Army were caused largely by conditions in 
civil life. 

Moreover, one has but to consider the clinical manifestations of 
these diseases to appreciate the truth of this statement; hemiplegia, 
optic neuritis, iritis, tabes, general paresis, gonorrheal arthritis and 
gonorrheal endocarditis are but a few of the many effects of syphilis 
and gonorrhea. 

Posterity suffers even more severely; the varying manifestations of 
congenital syphilis, such as deafness, interstitial keratitis and mental 
defectives are only too commonly met with. Twenty-five per cent, of 
blindness in children is due to gonorrheal opthalmia, and the cost to 
the State for the education of each blind child exceeds $4500. It is 
estimated that the total annual loss from gonorrheal ophthalmia in 
the United States is $7,000,000, and that more than $1,000,000 annually 
is spent in partially caring for its victims. 

In addition to the effects on the individual members of the com- 
munity the cost to the State is mainly an economic question. Millions 
of dollars have been expended yearly for the care of the insane, and from 
10 to 20 per cent, of these are of syphilitic origin. There are probably 
not less than 15,000 potential paretics in the State of New York. 

The cost of the venereal diseases includes not only the capital or 
earning power lost by death, but the waste of the vital forces of the 
individual, disabling him for weeks, months, or perhaps for years 
previous to death, and at the period of his greatest usefulness and pro- 
ductive capacity, and this cost falls largely upon others than the indi- 
vidual affected, namely, upon the employers of labor and the com- 
munity generally. This cost is yearly on the increase. 

The influence of syphilis and gonorrhea on vital statistics is un- 
doubtedly large, although proof of this is impossible at present. 
These diseases are seldom given as cause of death on death certificates; 



THE VENEREAL DISEASES 145 

only the results. But these results show plainly the effects of the 
venereal diseases on the mortality-rates. 

Let us consider first the effects on infant mortality. Mott reports 
one series of 34 mothers infected with syphilis in which there were 
175 confinements, which yielded 104 infant deaths and 41 seriously dis- 
eased children; only 31 children were apparently healthy. Another 
series of 1001 pregnancies, reported by the same writer, resulted in 172 
stillbirths and 229 infant deaths; of the 600 children who lived only 
200 were healthy. It is estimated that stillbirths are three times as 
frequent among syphilitic women as among the non-syphilitic. The 
birth-rate of any community would no doubt be considerably higher 
if it were not for the sterility resulting from gonorrheal salpingitis and 
oophoritis in the female and epididymitis in the male. 

It has long been recognized that certain diseases such as aortic 
aneurysm, cerebral apoplexy in early life (before the age of forty), 
tabes, and general paresis were syphilitic in origin, but the recent 
investigations of Warthin have clearly demonstrated that many other 
conditions heretofore unsuspected, are due to the same cause. In 40 
per cent, of 750 autopsies made by this investigator, syphilitic lesions 
were found in various tissues, such as the heart muscle, the arterial 
walls and other viscera. Without question syphilis is a contributory 
cause, if not the actual cause, of death in a great many of these cases. 

In the same way gonorrheal infection, though rarely appearing as 
a cause of death in cases of acute endocarditis, is a contributing cause 
of death in a great many of these cases. Cystitis with subsequent 
septicemia often has its inception in a strictured urethra. Women not 
infrequently die as the result of pus infection of the tubes and ovaries, 
which were originally infected by the gonococcus. 

This group of diseases constitutes the greatest of modern plagues. 
They are both preventable and curable; yet so vast is the extent of the 
social evil, so deeply is this problem rooted in private life, and so closely 
is it interwoven with other kindred problems still awaiting solution, 
such as prostitution and alcoholism, that at times it would seem almost 
hopeless to expect ever to solve it at all. Indeed, until New York City, 
in 1912, determined to treat the venereal diseases as any other com- 
municable and preventable infection, regarding them only from a 
public health standpoint, and ignoring their social and moral features, 
no serious effort was made by the sanitary authorities of any of our 
larger cities to solve the problem. Although progress against these 
diseases has been very slow, and the difficulties to be met and over- 
come, in this case, are much greater than in any other group of com- 
municable diseases, it is believed that an intelligent campaign per- 
sistently carried on, along the lines of sanitation and hygiene, will 
eventually result in their successful, if long-delayed, control The 
effort to do so at least must go on. The two principal venereal diseases 
are syphilis and gonorrhea, to which a third subordinate one may be 
added, viz., chancroid. 
10 



140 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

Syphilis. — Syphilis is a specific disease of slow evolution, propa- 
gated by inoculation (acquired syphilis). The infection itself, or various 
defects from the consequences of syphilis, may be transmitted (con- 
genital syphilis) from parent to child, often with fatal results. 

Syphilis in nature, so far as is known, appears only in man. The 
disease, however, has been produced in monkeys and rabbits by the 
inoculation of human virus. The course of the disease in man is divided 
into three stages: primary, secondary and tertiary. The initial or 
primary lesion occurs in the form of a papule which develops into the 
so-called chancre with hardened base. Following this there is hyper- 
plasia of the nearest lymph nodes. These lesions subside and six or 
seven weeks later the secondary lesions appear in various general 
eruptions on the skin and mucous membranes and in constitutional 
disturbances. The tertiary lesions, which consist principally of the 
masses of new tissue called gummata are found throughout the viscera 
and in the periosteum. A fourth stage is often added, consisting of the 
sequela? of syphilis, such as general paresis, arteriosclerosis, locomotor 
ataxia, aneurysm, etc. Schaudinn's spirochetes, the causative agent 
of the disease, have been demonstrated in practically all the lesions of 
syphilis, including the congenital type. 

Natural immunity in syphilis is very peculiar. After the develop- 
ment of the primary lesion, man is usually insusceptible to inoculation 
during the active stage of the disease, but during all stages both man 
and monkey can, in some cases, be reinoculated. Reinoculation in the 
tertiary stage gives precocious lesions of the tertiary type, gummata 
and tubercles. 

The infection in syphilis in the large majority of cases, is trans- 
mitted in venery, but non-venereal syphilis is more common than 
generally supposed by accidental or indirect contact with discharges 
from lesions. 

Infectious Agent. — The infectious agent is the Treponema pallidum 
(Schaudinn and Hoffmann). 

Source of Infection. — The source of infection is the discharges from 
the lesions of the skin and mucous membranes, and the blood of infected 
persons, and articles freshly soiled with such discharges or in which the 
Treponema pallidum is present. 

Mode of Transmission. — The mode of transmission is by direct 
personal contact with infected individuals, and indirectly by contact 
with discharges from lesions. Rarely it may be contracted from 
infected utensils. 

Incubation Period. — The incubation period is about three weeks. 

Period of Communicability. — The period of communicability is as long 
as the lesions are open upon the skin or mucous membranes and until 
the body is freed from the infecting organisms, as shown by micro- 
scopic examination of material from ulcers and by serum reactions. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the disease by the clinical symptoms, confirmed 



THE VENEREAL DISEASES 147 

by microscopical examination of discharges and by serum or spinal 
fluid (Wassermann) complement-fixation reactions. 

2. Isolation. — Exclusion from sexual contact and from preparation 
or preserving of food during the early and active period of the disease, 
otherwise none, unless the patient is unwilling to heed, or is incapable 
of observing, the precautions required by the medical adviser. 
. 3. Immunization. — Xone. 

n. General Measures. — 1. Education in matters of sexual hygiene, 
particularly as to the fact that continence in both sexes and at all ages 
is compatible with health and development. 

2. Provision for accurate and early diagnosis and treatment in hospitals 
and dispensaries, of infected persons, with consideration for privacy of 
record, and provision for following cases until cured. Facilities for 
physicians to have Wassermann tests made by Departments of Health. 

3. Repression of prostitution by use of the police power and control 
of use of living premises. 

-1. Restriction of the sale of alcoholic beverages. 

5. Restriction of advertising of services or medicines for treatment of 
sex diseases, etc. 

6. Abandonment of the use of common towels, cups, and toilet 
articles and eating utensils. 

7. Exclusion of persons in the communicable stage of the disease from 
participation in the preparing and serving of food. 

8. Personal prophylaxis should be advised to those who expose them- 
selves to opportunity of infection. (Calomel ointment, 33| per cent., 
applied within an hour of intercourse is generally effective in preventing 
syphilitic infections.) 

Gonorrhea. — Gonorrhea is a specific disease communicated by con- 
tact infection; in almost all cases among adults it is transmitted by 
sexual intercourse. It is more prevalent than syphilis and though in 
many cases quickly recovered from it often leads to most serious 
lesions. The total harmful effect on the race probably equals that of 
syphilis. Gonorrheal infection is usually restricted to the mucous 
membranes of the urethra, prostate, neck of bladder, cervix uteri, 
vagina, and conjunctiva. The conjunctival, vaginal and rectal mucous 
membranes are much more sensitive in early childhood than in later 
life. Gonorrheal ophthalmia is thus a frequent accidental infection 
at birth, and vaginitis in the young child is often produced by the 
carelessness of the nurse or mother carrying the infection. 

The usual course of the inflammation is as follows: The infection 
first takes place upon the mucous membranes which show congestion, 
infiltration with serous exudate and accumulation of leukocytes. It 
then penetrates the epithelial layer down to the submucous connective 
tissue. Recovery or prolonged chronic inflammation may then occur. 
The original infection of the urethra or vagina and cervix may remain 
localized or spread to adjacent parts, or through the blood, be carried 
to all parts of the body. The complications and sequelae of gonorrhea 
may thus be endometritis, metritis, salpingitis, oophoritis, peritonitis, 



I is PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

prostatitis, cystitis, epididymitis and arthritis. Abscesses of consider- 
able size, periostitis and otitis are occasionally due to this infection. 
Cases of gonorrheal endocarditis and septicemia are not infrequent. 
General gonorrheal infections are often followed or accompanied by 
neuralgic affections, muscle atrophies and neuritis. Gonorrhea is more 
frequent in males than in females, but gonorrheal arthritis of great 
intensity may occur in a newly married woman infected by an old 
gleet in her husband (Osier) . There is no limit to the time during which 
a man or woman may remain infected with gonorrhea and infect others. 
We have had one case under observation where twenty years had 
elapsed since exposures to infection, and yet the gonococci were still 
abundant. It is now well established that most of the inflammations 
of the female genital tract are due to gonorrhea, and the majority of 
such infections are produced in innocent women by their husbands 
who are suffering from the latent disease. At least one-half of all cases 
of sterility is said to be caused by gonorrhea. Immunity after recovery 
from the disease seems to be only slight in amount and for a short 
period, if present at all. 

Infectious Agent. — The infectious agent is the gonococcus (Neisser). 

Source of Infection. — The source of infection is the discharges from 
lesions of inflamed mucous membranes and glands of infected persons, 
viz., urethral, vaginal, cervical, conjunctival mucous membranes and 
Bartholin's or Skene's glands in the female, and Cowper's and the pros- 
tate glands in the male. 

Mode of Transmission. — The mode of transmission is by direct per- 
sonal contact with infected individuals, and indirectly by contact with 
articles freshly soiled with the discharges of such individuals. 

Incubation Period. — The incubation period is from one to eight days, 
usually three to five days. 

Period of Communicability. — The period of communicability is as 
long as the gonococcus persists in any of the discharges, whether the 
infection be an old or a recent one. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the disease by the clinical symptoms, confirmed 
by bacteriological examination or serum reaction (Complement- 
fixation test). 

The bacteriological examination by smears and cultures usually 
fails to distinguish gonococci in the subacute and chronic cases. This 
is especially true in female cases. The complement-fixation test when 
properly carried out often gives valuable information in these cases 
when it is positive infection probably persists. 

2. Isolation. — When the lesions are in the genito-urinary tract, 
exclusion from sexual contact, and when the lesions are conjunctival, 
exclusion from school or contact with children, as long as the discharge 
contains the infecting organism. 

3. Immunization. — None 

n. General Measures. — 1. Education in matters of sexual hygiene, par- 
ticularly as to the fact that continence in both sexes at all ages is 
compatible with health and development. 



THE VENEREAL DISEASES 149 

2. Provision for accurate and early diagnosis, and treatment in hos- 
pital and dispensaries of infected persons with consideration for 
privacy of record and provision for following cases until cured. 

3. Repression of prostitution by use of police power and control 
of use of living premises. 

4. Restriction of the sale of alcoholic beverages. 

5. Restriction of advertising of services or medicines for the treatment 
of sex diseases, etc. 

6. Elimination of common towels and toilet articles from public places. 

7. Use of prophylactic silver solution in the eyes of the newborn 
(Crede's method). 

8. Exclusion of persons in the communicable stage of the disease from 
participation in the preparing and serving of food. 

9. Personal prophylaxis should be advised to those who expose them- 
selves to opportunity of infection (e. g., silver salts — injections of argyrol 
10 per cent, solution). 

10. Prevention of Ophthalmia Neonatorum. — This disease is usually 
but not always due to the gonococcus during pregnancy, women should 
daily cleanse the external parts with soap and water on a clean cloth. 
Immediately after birth when there is a possibility that the mother is 
infected, the eyelids should be carefully cleansed with a saturated solu- 
tion of boric acid on a swab of sterile gauze or absorbent cotton. A 
separate piece of cotton should be used for the lids of each eye. The 
lids should then be separated and one or two drops of a 1 per cent, 
solution of nitrate of silver dropped in each eye. The head should be 
so held and the lids separated so that the solution may lie for from one 
half to one minute upon them, so as to come in contact with every part. 

Substitutes such as 25 per cent, solution of argyrol and aqua chlorine 
are sometimes substituted. 

Chancroid. — Chancroid is a specific ulcer, caused by the Ducrey 
bacillus of soft chancre. 

The ulcers are often multiple and confer little or no immunity. They 
are local, and unless complications set in they produce no sequelae or 
constitutional disturbances. But chancroids are peculiarly liable to 
mixed infections, from which serious consequences may result. Among 
the complications of the ulcers are: phimosis, destruction of the frenum, 
gangrene, lymphangitis and inguinal adenitis (buboes). This infection 
is thus not always mild or trivial, and the same methods of control 
should be adopted for preventing it as in the case of the other venereal 
diseases. 

(The ulcer may be aborted by cauterization if not more than three 
days old, as advised by Keyes: Wash the ulcers with hydrogen 
peroxide, dry, apply carbolic acid (pure), and then nitric acid (pure); 
wash again with hydrogen peroxide and dust with calomel. Soap and 
water applied at time of exposure will prevent the development of 
chancroid.) 

General Discussion on the Control of the Venereal Diseases. — The 
venereal diseases being highly infectious and communicable, it stands 



150 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

to reason that similar measures must be adopted for their control as 
are employed for the control of other communicable disease. 

These measures may be grouped under four headings: 

I. Isolation and treatment of active cases of the diseases. 
II. Isolation and control of carriers. 
III. Control of the environmental factors necessary for the 

dissemination of the disease. 
IV. Public Health education in reference to the disease. 

I. The patient suffering with syphilis or gonorrhea should be sub- 
jected to such a degree of isolation as may be necessary for the indi- 
vidual ease. The intelligent person may need nothing more than 
instruction in the proper method of disinfection of the infective dis- 
charges and in the precautions which must be taken to prevent the 
spread of the disease. On the other hand, the less intelligent patient 
may require strict isolation until the infective stage of the disease is 
past. 

Early and skilful treatment is essential in controlling the spread of 
the venereal diseases; every case of syphilis or gonorrhea promptly 
and properly treated means not only one more case under supervision, 
but one less source of infection. 

To secure this result requires the suppression of two great evils: the 
patent medicine and the venereal quack. Since both of these owe their 
existence solely to advertising, they should be abolished by appropriate 
legislation forbidding their publication. This would also tend to dis- 
courage self-treatment and drugstore treatment, which are ineffective 
and help to keep alive sources of infection. The laws regarding dis- 
pensing of drugs without a prescription should be strictly enforced, in 
which physicians and druggists can greatly assist. 

To be successful, facilities for skilful treatment of the venereal dis- 
eases must be provided. The burden of this is placed entirely upon the 
medical profession, each individual member of which must either so 
perfect himself in the modern methods of diagnosis and treatment of 
the diseases that he is able to give his patient the skilful service required 
or he must be willing to refer the patient to some other physician who is 
competent to render such service. 

Since the morbidity of the venereal diseases is just as high among 
the poor as among the well-to-do, if not more so, provision should be 
made for treatment without expense of those who have not the means of 
paying. 

The Royal Commission on Venereal Diseases, as the result of its 
investigation of 1913-1916 in England, included in its report recom- 
mendations that each Borough and County in the Kingdom of Great 
Britain should establish "treatment centers" where care could be taken 
of the indigent; the expense of which was to be borne three-fourths by 
the Royal Government and one-fourth by the local authorities. 

In the United States like steps have recently been taken under the 
direction of the Interdepartmental Social Hygiene Board. A sum of 
$1,000,000 was appropriated by Congress to be used in the various 



THE VENEREAL DISEASES 151 

States (distributed in proportion to the population) for the suppression 
of venereal disease. During the first year of the appropriation the 
money was given to the States without provisional State appropriation. 
For the year 1919-1920 each State is required to furnish an equal 
amount in order to secure its allotment of the appropriation. These 
funds are divided into budgets, viz., for treatment, for education in 
social service, for repression, etc. As a result of this Federal activity, 
clinics and dispensaries have been established in many States and 
municipalities, and their value is becoming more and more apparent 
each month. 

II. The second step necessary to control the spread of the venereal 
diseases consists in measures for the control of chronic carriers of dis- 
ease. The active case must remain under treatment until cured, and 
not dismissed as clinically well and in a carrier condition; clinical 
evidence is no evidence of cure. Laboratory tests alone are proof of 
cure, and even here negative results cannot be depended upon. Many 
States have now a provision in their laws which requires an individual 
who is being treated for a venereal disease to report at regular inter- 
vals to his physician. If such conduct on the part of the patient is 
not adhered to, the physician is then empowered to report his name 
to the health authorities who take action in the case. 

In order to obtain knowledge of the whereabouts of carriers of 
venereal disease, some form of reporting cases is necessary. The most 
important item of such a report is a statement as to the source of infec- 
tion. The system most commonly used is known as the Australian 
system, whereby a patient is reported by serial number, the name to be 
divulged only if the patient refuses to conform to the regulations of 
the health authorities. Upon receipt of this report the health officer is 
expected to communicate with the person named as the source of infec- 
tion, with the object of confirming or disproving the statement and of 
treating the individual if found to be infected. Procedures of this kind 
have been tried and proved to be successful. 

Again, the health authorities should have the right to examine 
persons whom they may have reasonable grounds to suspect of being 
infected with venereal disease. It needs no argument to prove that the 
prostitute would always be a member of this group. Such a person 
should be examined and if found infected should be treated until cured. 
In the meantime the individual should be strictly isolated, for as a 
general rule the prostitute depends entirely upon the proceeds of her 
trade and is incapable of self-support by any other means. 

Certain occupations, such as those of barbers, manicurists, masseurs, 
should be forbidden to persons suffering with syphilis; and no case of 
gonorrhea should be allowed to engage in any occupation in which he 
or she may be brought into contact with children. 

III. The third important factor to control the spread of the venereal 
diseases is the suppression of those influences which aid in the dissemi- 
nation of these diseases. This is a social aspect of the problem. It 
involves the question of better housing conditions, of the control of the 



152 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

liquor traffic, especially of the "back-room" variety, of the supervision 
of parks and dance halls, and, greatest of all, the abolition of the red- 
light district. 

It has been thought in the past by well meaning persons that segre- 
gation of prostitution was the proper solution of a necessary evil. But 
the reverse has been proved many times; particularly has this been 
shown in connection with the Army during the recent war. It has 
been demonstrated beyond question that the venereal disease rate in 
the army is far less than in the civilian population, and activities 
directed against the segregated districts have lowered the morbidity 
in many cases in the surrounding community. Some hold that the 
woman in the house of prostitution takes better care of herself than 
the "street walker." This may be so, but if the woman is infected she 
will surely infect more men in any given time in the house of prostitu- 
tion than will the street walker, for her opportunities are from three 
to ten times as great. Furthermore, the red-light district creates its 
own market; men who might otherwise refrain from such association 
may be tempted by the segregated district as being easier of access. 
Lastly, it has been shown that the number of street walkers lessens 
with the abolition of the segregated district. The registration and 
examination of prostitutes does not insure health, such examination 
being cursory at best. Infection may occur immediately after examina- 
tion and not be discovered for days. In addition to giving a false sense 
of security, it does not reach the clandestine prostitute, the chief 
source of venereal infection. The elimination of prostitution has been 
called "a dream of the theoretical reformer." Nevertheless it is our 
duty to take cognizance of existing prostitution and, wherever found, 
to do everything in our power to eradicate it. 

Alcohol is inextricably bound up with the venereal problem. Venus 
and Bacchus have ever been associates. The physiological effect of 
alcohol is to excite the organs of reproduction at the same time that it 
lowers the moral sensibilities and diminishes the will-power to resist 
temptation. With the advent of prohibition or the control of the manu- 
facture of alcohol as a beverage, it would seem that there should be a 
consequent reduction of venereal diseases. 

Experience in the Army, however, has shown that one cannot remove 
all these environmental factors without furnishing some substitutes for 
them. The activities of the Young Men's and the Young Women's 
Christian Associations, and various other organizations, have yielded 
wonderful results among the soldiers in this respect. Wholesome 
recreation must be provided to take the place of harmful amusements. 
Supervised dancing must replace the disreputable dance halls; club- 
rooms must replace the saloons; outdoor playgrounds must replace the 
dives, and these should be provided at community expense if we are to 
profit by the lessons which the war has taught us. 

IV. It is an accepted rule in public health that measures of control 
cannot progress far in advance of public opinion. The public has so 
long been kept in ignorance of the extent, nature and dangers of the 






TETAXVS 153 

venereal diseases, that education is necessary to gain their support and 
cooperation in the prevention of these diseases. Heretofore this sub- 
ject was not considered one suitable for decent people to discuss; 
children have grown up in ignorance of the true facts or learned what 
they knew, much of it incorrect and harmful, from companions as 
ignorant as themselves, on the street or in school : and in the meantime 
the plague has extended. 

Recently a campaign of education in social hygiene has been inaugur- 
ated which is nation-wide, and the public has been found in a receptive 
mood. The people have been approached in all possible ways, by mov- 
ing pictures, stereopticon lectures, pamphlets, circulars, posters, letters 
and personal appeals. In the last analysis it is by means of public 
health education that our goal will be achieved. Then the demand 
for drastic regulations to control the venereal diseases will be made by 
the public and these regulations will be enforced, which in turn will 
lessen the need of such health legislation. 

Individual Prophylaxis. — As a result of the experiments of Metchni- 
koff and Roux with syphilitic inoculation of the higher apes, it was 
found that syphilitic infection could be aborted by use of certain 
prophylactic measures. These consist of thorough washing with soap 
and water followed by inunction of the genitals with 33§ per cent, 
calomel ointment, the ointment to be left on the skin for eight horns or 
more. It has been shown that an injection of 25 per cent, argyrol into 
the urethra will in like maimer prevent gonorrhea. To insure success 
in individual prophylaxis it should be accomplished within two hours 
after exposure. After eight hours its effect is practically nil. 



TETANUS. 

Tetanus "lock-jaw") is an infectious disease, characterized by a 
gradual onset of general spasm of the voluntary muscles, commencing 
in those of the jaw and neck, and extending in severe cases to the 
muscles of the body. The disease is usually associated with a wound. 
Like diphtheria, tetanus is a type of the true toxemias. 

The disease has long afflicted man. having been clearly described by 
Hippocrates. The specific causative agent, the bacillus of tetanus, occurs 
widely disseminated throughout the world as a common inhabitant 
of the soil, especially garden earth where manure has been thrown. It 
is abundant in many places not only in the superficial layers of the soil. 
but also at the depth of several feet. It has been found in various 
substances, such as hay-dust, horse and cow manure its normal 
habitat is the intestines of herbivora) in the dust of rooms in houses, 
barracks and hospitals. The bacilli are more numerous in some locali- 
ties than in others, for example, in certain parts of Long Island and 
Xew Jersey, they are fairly common in New York City. As a rule, 
they are most abundant in regions where the temperature is high as in 
the tropics, where cases of puerperal tetanus and tetanus neonatorum 



i:>l PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

are very frequent. Tetanus bacilli are found in the intestines of about 
1 ."> per cent, of horses and calves living in the vicinity of New York City. 
They arc also present to a less extent in the intestines of other animals, 
and of man. The term "idiopathic tetanus" is used when the site of 
the bacillus is unknown. • 

Although tetanus may be regarded as almost entirely a wound com- 
plication, all wounds are not equally susceptible to the infection. 
Punctured, lacerated and contused wounds are much more liable to 
become infected than clean-cut or superficial wounds. Fatal tetanus 
may develop from slight scratches, small splinters, insect bites, vac- 
cinations, etc. The wounds produced by blank cartridges are especially 
liable to develop tetanus, due to the peculiar character of the wound. 
The number of cases of tetanus following Fourth of July wounds has 
recently decreased owing to the campaign carried on by the American 
Medical Association for a safe and sane celebration, the more thorough 
and careful treatment of the wounds, and especially the use of tetanus 
antitoxin as a prophylactic. 

Infecting Agent. — The infecting agent is the Bacillus tetani. 

Source of Infection. — The source of infection is animal manure, and 
soil fertilized with animal manure, and, rarely the discharges from 
wounds. 

Mode of Infection. — The mode of infection is by inoculation or wound 
infection. 

Incubation Period. — The incubation period is six to fourteen days, 
usually nine days. 

Period of Communicability. — The patient is not infectious except in 
rare instances where wound discharges are infectious. 

Methods of Control. — I. The Infected Individual and His Environ- 
ment. — 1 . Recognition of the disease by the clinical symptoms, which 
may be confirmed bacteriologically. 

2. Immunization by antitoxin, single or repeated injections. 

n. General Measures. — 1. Supervision of the practice of obstetrics. 
2 Educational propaganda, such as a "safety-first" campaign, and 
"safe, and sane Fourth of July" campaign. 

3. Prophylactic use of tetanus antitoxin where wounds have been 
acquired in regions where the soil is known to be heavily contaminated, 
and in all cases where wounds are punctured, lacerated or contused. 1 

4. Supervision of biological products, especially vaccines and sera. 

5. Removal by thorough treatment of all foreign matter from wounds 
as early as possible. If symptoms of tetanus, give antitoxin. 



1 In every case strongly suspected of being tetanus, from 3000 to 5000 units of tetanus 
antitoxin should be given at the first possible moment intraspinally, slowly by gravity, 
and always, if possible, under an anesthetic. To insure its thorough dissemination 
throughout the spinal meninges the antitoxin should be diluted if necessary, to a volume 
of from '.i to 10 c.c. or more, according to the patient's age. When fluid is drawn off 
previously to the uiving of the antitoxin an amount of the latter somewhat less than 
thai of the fluid withdrawn should bo given. In cases of "dry tap" only a small amount 
of tetanus antitoxin should be injected (3 to 5 c.c). 



MALARIA 155 



MALARIA. 



The discovery by Laveran that the mosquito was the intermediate 
host that conveyed the parasites of malaria to man was one of the 
most important ever made. Malaria is most severe and prevalent in 
the tropics, but may be present in any part of the world where the 
anopheles can breed. It is most prevalent near the equator. 

There is little, if any, direct communicability. The one infected 
may think himself cured and have relapses. In malarious regions 
many children are carriers without apparently showing any disturb- 
ances. These are a constant source for mosquito infection. Exposure, 
overeating and anything which lowers resistance predispose to relapses 
and to the probability of infection. The difficulties of destroying 
the anopheles in extensive areas is very great. Where population is 
fairly dense it can be done. Where sparse, the treatment with quinine 
of carriers by suppressing the source of mosquito infection is the most 
promising method and will accomplish much and should be accom- 
panied by quinine treatment as a preventive for the well. The adult 
dose is usually 5 to 7 grains daily. Drainage and treatment of low 
places by filling in offer the best success. Bass found that 90 per cent, 
of malaria could be eliminated from any region, if physicians, health 
officers and public worked together to diminish it. 

Infectious Agent. — The several species of malarial organisms — Plas- 
modium malaria?, P. vivax and Laverania malaria?. 

Mode of Transmission. — By bite of the infected Anopheles mosquitoes 
(Figs. 18 and 20). The mosquito is infected by biting an individual 
suffering from acute or chronic malaria. The parasite develops in the 
body of the mosquito for from ten to fourteen days, after which time 
the sporozoites appear in its salivary glands. 

Incubation Period. — Varies with the type of species of infecting 
organism and the amount of infection; usually fourteen days in the 
tertian variety. 

Period of Communicability. — As long as the malaria organism exists 
in the blood. 

Methods of Control. — The Infected Individual and His Environment. 
— 1. Recognition of the Disease. — Clinical symptoms, always to be con- 
firmed by microscopic examination of the blood. Repeated examina- 
tions may be necessary. Quinine in sufficient doses should be con- 
tinued until cures are established. It is estimated that persons who 
have second attacks during the year suffer in at least 50 per cent, 
from relapses and not new infections. Bass recommends \ grain of 
quinine every night before retiring for infant of one year; 3 grains, five 
years; 8 grains, fifteen years, and 10 grains for older persons. The 
treatment to be continued for eight weeks. About 40 per cent, of all 
infected persons do not realize it. These and those who treat them- 
selves insufficiently are the ones who keep up the infection. 

2. Isolation. — Exclusion of patient from approach of mosquitoes, 
until his blood is rendered free from malarial parasites by thorough 
treatment with quinine. 



156 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

3. Im munization. — None. The administration of prophylactic doses 
of quinine should be insisted upon for those constantly exposed to 
infection and unable to protect themselves against mosquitoes. 

4. Destruction of Anopheles mosquitoes in the sick room during 
illness and after recovery. 

n. General Measures. — 1. Employment of known measures for 
destroying larvae of anophelines and the eradication of breeding places 
of such mosquitoes. There are drainage, filling in hollows, modify- 
ing streams, oiling by kerosene every ten days, screening wells, 
cisterns, etc., removal of plants likely to contain water, introduction 
of fish, etc. 

2. Blood examination of persons living in infected centers to deter- 
mine the incidence of infection. 

3. Screening sleeping and living quarters and use of mosquito nets 
in order to reduce the number of infections in man and mosquitoes. 

4. Killing mosquitoes in living quarters. 

YELLOW FEVER. 

The yellow fever mosquito is distributed between the latitude of 
38 degrees south and 38 degrees north. It is found abundantly south 
of the Potomac River along the coast. It is absent in the higher eleva- 
tions of Georgia and Alabama. The mosquito breeds by preference in 
any standing water about the house grounds, such as cisterns, rain 
barrels, empty jars, etc. It does not breed in swamps and does not 
fly to any great distance. It is chiefly active by day. It cannot pass 
a screen composed of 19 strands to the inch. 

Infectious Agent. — Unknown. Xoguchi claims that a spirochete 
(Leptospira icteroides) discovered by him is the probable cause. 

Source of Infection. — The blood of infected persons. 

Mode of Transmission. — By the bite of infected Aedes calopus mos- 
quitoes. 

Incubation Period. — Three to five days, occasionally six days. 

Period of Communicability. — First three days of the fever. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the Disease. — Clinical symptoms. 

2. Isolation. — Isolate from mosquitoes in a special hospital ward or 
thoroughly screened room. If necessary the room or ward should be 
freed from mosquitoes by fumigation. Isolation necessary only for 
the first three days of the fever. 

3. Immunization. — None. 

4. Quarantine. — Contacts for six days. 

5. Concurrent Disinfection. — None. 

0. Terminal Disinfection. — None. Upon termination of case the 
premises should be rendered free from mosquitoes by fumigation. 

n. General Measures. — Eliminate mosquitoes by rendering breeding 
impossible. Removal of all vessels, tubs, etc., that hold stagnant 
water. Introduction of suitable and abundant fish to feed on larva?. 




S/ 1/ 

1 A 



Fig. 13 



Fig. 14 




Fig. 21 Fig. 22 

Chief comparative characteristics of culex and anopheles. Egg of culex, Fig. 13, laid 
together in "small boat," those of anopheles, Fig. 14, separate and rounded. Larva of 
culex, Fig. 15, hangs nearly at right angles to water surface, those of anopheles, Fig. 16, 
are parallel to surface. Body of culex, Fig. 17, when resting is held parallel to wall in a 
curved position, that of anopheles, Fig. 18, stands at an angle of about 45 degrees and 
is straight; wings of culex, Fig. 19, are generally not spotted, those of anopheles, Fig. 20, 
are spotted. In culex the palpse, Fig. 21, of the female are very short, of the male are 
longer than the proboscis; in anopheles, Fig. 22, the proboscis of both sexes are about of 
equal length. (From Kolle and Hetsch.") 



158 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

HI. Epidemic Measures. — 1. Inspection service for the detection of 
those ill with the disease. 

2. Fumigation of houses in which cases of disease have occurred, and 
of all adjacent houses. 

:\. Destruction of Aedes calopus mosquitoes by fumigation; use of 
larvieides; eradication of breeding places. 



RABIES. 

Rabies (Hydrophobia.) — An acute infectious disease of mammals 
dependent upon a specific virus, and communicated to susceptible 
animals by the saliva of an infected animal through abrasion of skin 
or mucous membranes almost always by bites or scratches. 

Within the gray nervous tissue of rabid animals are peculiar proto- 
zoon-like structures known as "Negri bodies" which are diagnostic of 
rabies. They are thought by some to be the probable exciting factor, 
although this is disputed by others. 

Incidence. — Rabies exists in almost all parts of the world. The only 
country in which it has never been known is Australia, probably 
because there are but few marsupial animals there, and dogs have 
always been under strict control. Hydrophobia is very rare in Norway, 
Sweden, Denmark, Holland, Switzerland and North Germany, w T here 
dog laws are in force; while it is most common in Russia, France, 
Belgium, Italy and Austria where such laws are lax or absent. The 
disease is comparatively infrequent in South America, Mexico and 
Canada, in this part of the world; but in the United States it is ap- 
parently on the increase, owing to the general neglect of legislative 
measures for the control of rabies Recently the disease has been 
eradicated from England by the enactment of laws requiring the 
muzzling and later quarantine of dogs coming into the country. 

All warm-blooded animals are more or less naturally susceptible to 
hydrophobia, but it occurs most frequently in dogs, among domestic 
animals, and in wild animals of the canine species, such as wolves, 
foxes, jackals and hyenas. It occasionally occurs in cats and skunks, 
more rarely in cattle, sheep, goats, horses, cows and pigs. 

Rabies is one of the most fatal diseases, recovery seldom or ever 
taking place after the symptoms become developed. 

The disease occurs at all seasons of the year, although it is commonly 
supposed to prevail most in the hot months of summer, the reason for 
this being simply that dogs are liable to run abroad more freely at this 
time than in the winter. Hot weather has no influence on the disease; 
cold, indeed, seems to aggravate it. 

Neither age, sex, nor other conditions have any effect upon the 
production of the disease in man, but occupation, so far as this relates 
to exposure to infection, may possibly influence the number of cases. 
Thus those persons who are much in the country or on the streets, or 
in other words, those who might come most often in contact with rabid 
animals, most commonly contract the disease, 



RABIES 



159 



Transmission. — While all mammals are subject to rabies, the disease 
is transmitted and disseminated, in civilized countries at least, almost 
exclusively by dogs. The virus is contained in the saliva of the rabid 
animal, and is usually communicated to man through a bite. The bite 
of such infected animal may produce the disease from eight to fifteen 
days before the symptoms of rabies develop. Hence if an animal be 
kept under observation for three weeks after the bite without develop- 
ing symptoms, he may be pronounced free of rabies. 

The certainty with which the disease may be produced after a bite 
and the rapidity of its development have been found to depend: (1) 
on the quantity of the rabic virus introduced; (2) on the point of inocu- 
lation; and (3) on the strength of the virus as determined by the kind 
of animal which affords the cultivation ground for the development 
of the poison. It has been observed in man that slight wounds of the 
skin, of the limbs, and of the back, or wherever the skin is thick and the 
nerves few, either produce no results, especially when bites are through 
the clothing, or are followed by the disease after an extremely long 
period of incubation; while in lacerated wounds often tips of the 
fingers where small nerves are numerous, or where the muscles and 
nerve trunks are reached, or in lacerated wounds of the face where 
there is also an abundance of nerves, the incubation period is usually 
much shorter and the disease generally more severe. 

These facts explain why only about 16 per cent, of human beings 
bitten by rabid animals, and untreated, appear to contract hydro- 
phobia. They also explain why the bites of savage animals like wolves 
are the most dangerous because of the torn and lacerated nature of the 
wounds produced. 

Infection, however, may be caused in other ways than through bites. 
The mere licking of the bare hand or face; if they have a slight scratch 
or abrasion, by a rabid animal may result in infection. There is special 
danger from this source in handling sick dogs, when they show no 
definite symptoms, or possibly only a slight suspicion of beginning 
rabies. In handling such animals, therefore, the hands and face should 
be properly protected. Infection may also take place in dissecting a 
rabid animal that has died of the disease or been killed. 

Incubation. — There is always a period of incubation after the bite 
of quite variable duration. As a rule it is from twenty to sixty days. 
The shortest period recorded is fourteen days and the longest authentic 
period is seven months. A few cases have been reported as developing 
after a year or more, but these cases may be considered as of doubtful 
authenticity. 

The wound heals like any other wound and sometimes shows no 
further symptoms. Occasionally, however, redness and swelling of the 
scar may occur; oftener there are pains extending from the scar along 
the nerve paths of the brain. 

Symptoms. — The symptoms may be divided into three stages: (1) 
the prodromal stage; (2) the excited or convulsive stage; and (3) the 
paralytic stage. When the second stage is the most pronounced, the 



L60 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

disease is railed furious or convulsive rabies; when this stage is very 
short or practically lacking and paralysis begins early, the disease is 
called dumb or paralytic rabies. 

/// the dog rabies appears in the two typical forms: the furious and 
the paralytic. The principal symptoms of each form may be summar- 
ized as follows: 

Furious Rabies. — Change of behavior, biting (especially at those to 
whom the animal has been affectionate before), characteristic restless- 
ness and aggressiveness with a tendency to run long distances, loss 
of appetite for ordinary food with desire to eat unusual things, the 
animal does not fear water, as the name hydrophobia erroneously 
implies, but has difficulty in swallowing and runs about attacking all 
objects in its way, intermitted disturbance of consciousness, paraxysms 
of fury, peculiar bark or howl, rapid emaciation, paralysis beginning 
in the hind limbs, and death in three to six days (exceptionally slightly 
longer) after the beginning of symptoms. 

Paralytic Rabies. — Short period of excitation (which may be incon- 
spicuous, the animal fawning upon its master), paralysis of the lower 
jaw, hoarse bark, appetite and consciousness disturbed, weakness with 
paralysis spreading in a great majority of cases, and death four to five 
days after the first symptoms. There may be a number of cases show- 
ing transition types between these two forms, but all rabid animals 
become paralyzed before they die. Death takes place as a rule on the 
third or fourth day after symptoms have developed, but a few cases 
have been reported of death occurring after longer intervals. 

In Human Beings. Furious Rabies. — The first definite symptoms 
are difficult and gasping breath with feeling of oppression and difficulty 
in swallowing, the latter the most characteristic symptom. It is caused 
by convulsive contraction of the throat muscles, attacks being brought 
on when attempting to drink or swallow. The convulsive attacks 
finally become more or less general over the wdiole body; in certain 
cases some parts are more affected by reflex excitation than others, as, 
for instance, there may be slight or no photophobia, while in exceptional 
cases, more frequently in dogs, the hydrophobia or fear of swallowing 
is also absent. Most of the special reflexes are increased. Pupils 
become irregularly contracted and widened until they remain fixed. 

Human beings are seldom dangerous to. the people about them ; they 
do not make aggressive bites. In their convulsions they may bite 
things placed between their teeth, but not otherwise. At this time 
there is an increased flow of saliva, and one should avoid the contact of 
this with opened wounds. It may be so increased that the patient may 
try to get rid of it by taking it from the mouth with the hand and throw- 
ing it about. As a rule, however, the patient has full possession of his 
senses between the convulsive attacks until very late in the disease. 

The temperature is increased from 38° to 40° C, at first with morn- 
ing remissions. Just before death it may rise as high as 42.8° C. 
(In the lower animals the temperature sinks below normal just before 
death. J The pulse is generally over 100 and is irregular. This stage 






RABIES 161 

lasts from one to four days. Death may occur during a convulsion , but 
more often there is a paralytic stage, which lasts from two to eighteen 
hours. The convulsions become less frequent and the patient becomes 
weaker until there is a complete paralysis. At the beginning of this 
stage the patient may be able to drink water better than formerly. 
Death may occur at any time through paralysis of the heart or respira- 
tory center, usually on the third or fourth day. 

Paralytic Rabies. — This form occurs seldom in human beings, more 
frequently in dogs, but not so often as the convulsive form. It is sup- 
posed to occur in humans and dogs after a more severe infection. 
Instead of periods of convulsions, the various muscles simply tremble 
and become gradually weaker until complete paralysis supervenes. 
Sometimes paralysis develops very quickly and may be general before 
death from syncope or asphyxia occurs. This form generally lasts 
longer than ordinary rabies. Between these two typical forms of rabies 
there are many different types. In paralytic rabies the average time 
of death is on the fifth day. 

Diagnosis. — The positive diagnosis of rabies can be made only by 
laboratory methods. While the symptoms above described may be 
suggestive, they must always be confirmed by the findings in the 
pathological lesions or by animal tests. 

Since 1906, in our routine work in the New York City Health Depart- 
ment Laboratories, we have considered the presence of the Negri 
bodies in smears made from the fresh brain as diagnostic of rabies, and 
have made no further tests except in those cases which were used for 
experimental purposes. In this experimental work, however, we have 
added many hundred cases to the list of those which had comparative 
tests, and our former conclusions have been firmly established. In all 
our work controlled by careful animal inoculations we have never 
failed to have typical rabies develop in animals inoculated with material 
showing definitely structured Negri bodies. So far we have not had 
rabies produced by fresh brains showing no Negri bodies and no sus- 
picious forms; but a few observers have claimed that such material 
has produced the disease. Decomposing brains may show in smears 
bodies very similar to these tiny forms; in such cases, therefore, it is 
difficult to rule out rabies. For this reason, animal tests will probably 
always have to be made with brains too decomposed to show any 
formed elements except bacteria, and also in all cases in which only 
suspicious bodies have been found by microscopical examination, or 
at least until the technic has been standardized. In any case, however, 
we may be reasonably certain that when the fresh material examined 
microscopically is negative, it was not a case of rabies. 

Our conclusions regarding the value of the smear method in diagnosis 
may be expressed as follows: 

1. Negri bodies well demonstrated in fresh brains, diagnosis rabies 
(except 4). 

2. Negri bodies not demonstrated in fresh brains, probably not rabies 
(except 4) . 

11 



L62 PREVENTION OF IS DIVIDUAL INFECTIOUS DISEASES 

:\. Negri bodies not demonstrated in decomposing brains, uncertain. 

1. Suspicious bodies in fresh brains, probably rabies. 

The diagnosis of rabies by animal experimentation, which consists 
in placing a small quantity of the suspected material under the dura 
mater of a rabbit or guinea-pig, is final. But this method requires so 
much time (on account of the long incubation period of the disease), 
that it is of no practical value in deciding whether or not the Pasteur 
treatment should be given. In any doubtful case, however, the evi- 
dence furnished by animal experimentation is irrefutable. 

Disposal of Dogs Suspected of Rabies. — Should a dog be suspected of 
rabies it should not be killed (unless absolutely necessary), but securely 
fastened up by a chain in a kennel or enclosure, where no other animal 
or person can have access to it. If the dog has rabies paralysis will 
develop and the animal will die, usually in four or five days. If no 
paralysis develops, and the dog is alive and well at the end of two weeks, 
the disease is not rabies, and the animal may be safely released. 

If the animal has been killed, the brains should never be blown out, 
the head should be severed from the body by a sharp instrument (if 
the body is too large to ship) as near the thorax as possible, packed in 
ice in a watertight vessel, and forwarded at once to the laboratory for 
examination; care being taken during the operation and handling to 
protect the hands from infection. The hands and instruments used 
should later be thoroughly disinfected, and the carcass of the animal 
burned or deeply buried. 

Methods of Control. — I. The Infected Individual and his Environ- 
ment. — 1. Recognition of the Disease. — Clinical symptoms, confirmed by 
the presence of Negri bodies in the brain of an infected animal, or by 
animal inoculations with material from the brain of such infected 
animal. 

2. Isolation. — None if patient is under adequate medical super- 
vision, and the immediate attendants are warned of possibility of 
inoculation by human virus. 

3 . / m m a n ization — Preventive vaccination (Pasteur's treatment) .after 
exposure to infection by inoculation. 

4. Quarantine. — None. 

5. Concurrent disinfection of saliva of patient and articles soiled 
therewith. 

6. Terminal Disinfection. — Thorough cleansing. 

n. General Measures. — 1. Muzzling of dogs when on public streets 
or in places to which the public has access, and later quarantine of all 
dogs coming from other places, where rabies is prevalent. 

2. Detention and examination of dogs suspected of having rabies. 

W. Immediate antirabic treatment of people bitten by dogs or by 
other animals suspected or known to have rabies, unless the animal is 
proved not to be rabid by subsequent observation or by microscopic 
examination of the brain and cord. 

Registration, licensing and taxing, and leashing of dogs are restrictive, 
not preventive measures. The muzzling of dogs was adopted in 



RABIES 163 

England for a time, and rabies began to decrease. Then owing to 
false sympathy for the dog, the law was repealed, and rabies at once 
commenced to increase again. The law was once more enacted and 
relentlessly enforced for two years, when rabies disappeared entirely. 
A strict quarantine of six months is now maintained against all dogs 
in England, but dogs are no longer muzzled. Should the disease become 
prevalent, the law will again be enforced. Rabies is unknown in 
Australia, having been kept out by the enforcement of effective quar- 
antine measures. In Norway, Sweden and Denmark the disease has 
been absent for fifty years, owing to the wise provision of similar 
legislative control of dogs. New York City is now trying to enforce 
such laws. Other countries and cities can do the same. Were all dogs 
under strict legislative control, and the compulsory wearing of muzzles 
rigidly enforced for a period of two years, with later quarantine regula- 
tions, as above illustrated, hydrophobia would be stamped out; and in 
this way only can the disease be eradicated. 

There are facts which have been amply demonstrated by experience, 
but until the necessary drastic measures are taken to eradicate this 
wholly preventable infection, palliation methods of treatment must 
be adopted to reduce its mortality if not its prevalence. 

Local Treatment. — In wounds caused by the bite of an animal, when 
rabies is suspected, and the Pasteur preventive treatment cannot be 
applied, great benefit may be derived from the correct use of cauteriza- 
tion with fuming or strong nitric acid. This is effective twelve to 
twenty-four hours after the bite. Even in cases when the Pasteur 
treatment can be given, an early cauterization will be of much assist- 
ance as a routine practice; for the Pasteur treatment is often delayed 
several days for obvious reasons and thus does not always protect. 
In the case of slight wounds all the treatment probably indicated may 
be thorough cauterization with nitric acid, applied with a glass rod, 
within twelve hours from the time of infection. Our experience in 
dealing with persons bitten by rabid animals goes to show that physi- 
cians have not sufficiently appreciated the value of thorough cauteriza- 
tion of the infected wound. In the absence of nitric acid, the actual 
cautery may be used. Antiseptics are not to be relied on. Unless 
absolutely certain that the animal is not mad, all wounds produced by 
the bite of an animal should be cauterized. 

Pasteur's Method of Preventive Vaccination. — The old treatment of 
rabies consisted simply in encouraging bleeding from the wound, or 
in first excising the wound and then encouraging bleeding by means 
of ligatures, warm bathing, etc.; the raw surface was then freely 
cauterized with caustic potash, nitric acid, or the actual cautery. It 
is doubtful whether the disease ever manifested itself after such 
heroic treatment, if the wound were small and the treatment was begun 
soon after the bite; but when the wounds were numerous or extensive, 
the mortality was still high. As it was often impossible to apply 
cauterization to the wound rapidly or deeply enough to insure complete 
destruction of the virus, Pasteur and others were led to studv the dis- 



1C)4 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

ease experimentally in animals with the hope of finding some means 
of immunization or even cure; these investigations finally resulted in 
the discovery of methods of preventive inoculation applicable to man. 

Pasteur's treatment is based upon the fact that rabic virus may be 
weakened or intensified under certain conditions. He first observed 
that the tissues and fluids taken from rabid animals varied consider- 
ably in their virulence. Then he showed that the virus may be intensi- 
fied by successive passages through certain animals (rabbits, guinea- 
pigs), and weakened in passing through others (monkeys). If succes- 
sive inoculations be made into rabbits with virus, either from the dog 
or the monkey, the virulence may be so exalted beyond that of the 
virus taken from a street dog, that at the end of the fiftieth passage the 
incubation period may be reduced to about six or .seven days, when it 
remains fixed. This "fixed virus" was used by Pasteur, and others 
later, in his preventive treatment because the dose could be more 
definitely regulated by subsequent attenuation or dilution. 

hi the original method employed by Pasteur, a series of spinal cords 
from rabbits dead from "fixed virus" infection are cut into segments 
and suspended in sterile glass flasks plugged with cotton stoppers and 
containing a quantity of some hygroscopic material, such as caustic 
potash; these are kept at a temperature of about 22° C. The cord 
when taken out at the end of the first twenty-four hours is found to be 
about as active as the fresh untreated cord; that removed at the end of 
forty-eight hours is slightly less active; and the diminution in virulence, 
though gradual, progresses regularly and surely until, at the end of the 
eighth day the virus is inactive. Pasteur began his treatment with an 
emulsion of the cord kept until the fourteenth day. A certain quantity 
of this was injected into the animal that had been bitten; this was 
followed by an injection of an emulsion of a twelve-day cord, and so on, 
until the animal had been injected wdth a perfectly fresh, and therefore, 
extremely active cord, corresponding to the fixed virus. Animals 
treated in this way were found by Pasteur to be absolutely protected, 
even against subdural inoculation with considerable quantities of the 
most virulent virus; and thus Pasteur's protection vaccination became 
an accomplished fact. A series of experiments were carried out which 
led to the discovery that if the process of inoculation be begun within 
five days of the bite in animals, in which the incubation period was at 
least fourteen days, almost every animal bitten can be saved, and' that 
even if the treatment be commenced at a longer interval after the bite 
a certain proportion of recoveries can be obtained. Thus the applica- 
tion of this method of treatment to the human subject was not tried 
until it had been proved in animals that such protection was possible, 
and that it would last for at least one year and perhaps longer. 

The chance of success in the human subject appears to be even 
greater than in the dog or rabbit. Man's period of incubation is com- 
paratively prolonged. Thus there is an opportunity of obtaining 
immunity by beginning the process of inoculation soon after the bite 
baa been inflicted, the protection being complete before the incubation 
period has passed. 



RABIES 165 

Pasteur's original method has undergone modification in three 
general directions: (1) lengthening or shortening the period of treat- 
ment; (2) starting the inoculation with a less attenuated cord; (3) 
increasing or decreasing the amount given at each injection. The 
method of drying the cord, however, has remained comparatively 
little changed from that employed by Pasteur. 

An intensive method of treatment is now commonly used in preference 
to Pasteur's original method. This method is adopted in the New 
York Health Department Laboratories, the Hygienic Laboratory, 
Public Health Service, at Washington, D. C, and other places. In 
this method the first inoculation is made with the 8-day cord and by 
the eighth day a 1-day cord is inoculated. The treatment lasts twenty- 
one days. Each dose contains \ cm. of the indicated cord emulsified 
in 3 c.c. of normal salt solution, and 2| c.c. of this emulsion is inoculated. 

In other than very severe cases a 2-day cord is used for the first 
inoculation, instead of a 1-day cord. In cases with very slight wounds, 
which have begun treatment immediately, the inoculations are carried 
on only as far as the fifteenth day. 

Many Pasteur institutes now use a modified treatment starting with 
an 8-day or fresher cord, instead of the 14-day old cord. But at 
l'lnstitut Pasteur in Paris, and some others, the original schema is 
still employed, as first proposed by Pasteur. 

Results. — On the whole the results of protective inoculations against 
rabies are marked, when compared with the mortality statistics, after 
bites from animals suffering from hydrophobia, of those given after 
any other method of treatment; but these statistics not having been 
uniformly kept, it is difficult to analyze their value. 

Immunity appears two weeks after the treatment and in human 
beings lasts a variable time, which has not been accurately determined. 
That it may not last longer than fourteen months was shown by a case 
under our observation, in which an apparent reinfection occurred at 
that time. 

Effects of Treatment. — There is only slight local discomfort, as a rule. 
During the second week an erythema often appears about the point of 
inoculation but soon disappears. Occasionally, ever since the intro- 
duction of the treatment non-fatal affections of the nervous system 
have been reported, which occurred during or short time after the 
treatment. These affections have varied in degree from a slight 
neuritis through paraplegia to paralysis of different parts of the body. 
Very rarely the paralyses have been severe and the patient died. It 
should be noted that cases of true paralytic rabies may occur within 
the period required for the establishment of immunity by the treat- 
ment, and these must be differentiated from paralysis occurring as a 
result of treatment. 

Treatment by Mail. — The New York City Health Department was 
the first to send out treatment by mail to physicians for their own 
patients. Full directions accompany the mailing cases. One-quarter 
per cent, carbolic acid is added to the emulsion prepared as described 



166 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

for the first throe days' treatment; 20 per cent, glycerin is added to all 
other emulsions. These are added as preservatives and are therefore 
omitted when the virus is administered to patients at the laboratory. 
The results from the treatment sent in this way seem to be equally as 
good as those from the treatment given in the laboratory. 

Antirabic serum (prepared by Marie and others) has been used to 
some extent in the treatment of rabies; but though certain advantages 
have been claimed for this method over the original Pasteur treatment, 
it has not come into general use. 

PLAGUE. 

.(Bubonic, Septicemic, Pneumonic) 

An acute, fatal, specific, epidemic fever characterized by the forma- 
tion of boils, carbuncles, buboes and petechia?. 

This disease, wdiich in the Middle Ages became such a terrible 
scourge that it w r as known as the "black death," is still one of the most 
dreaded of the great epidemic infections. It has, however, been con- 
fined principally to Asia. Both in China and India there have been 
outbreaks of great severity in the last twenty years, and even in this 
hemisphere in certain parts of South America and the United States, 
occasional cases have occurred. Judging from the readiness with which 
it has been checked and limited wherever it made its appearance in 
this country, there is very little risk that the plague will ever assume 
again its former devastating power among civilized nations. 

Three types of the disease are now recognized: the bubonic, pneu- 
monic and septicemic forms. One of the most fatal forms of infection 
is that of the lungs. Pneumonic cases are not alone serious in them- 
selves, but they readily spread the infection. 

There is considerable immunity produced in this disease. Like 
typhoid infection, a single attack of the plague protects, with rare 
exceptions, from a second infection. 

Artificial immunity, active or passive, may be acquired in various 
ways. The active immunity produced by the vaccination of cultures 
(llarl'kine's prophylactic) protects partially for six months or more. 
Those that develop plague after vaccination have on the average a 
milder form. The passive immunity produced by the injection of 
antiplague serum lasts only about three weeks. 

Infectious Agent. — The infectious agent is the bacillus pestis. 

Source of Infection. — The source of infection is the blood of infected 
persons and animals and sputum of human cases of plague pneumonia. 

Mode of Transmission. — The mode of transmission is direct in the 
pneumonic form. In other forms the disease is generally transmitted 
by the bites of infected fleas which have fed on sick rats, by which the 
disease is carried from rats to man, also by fleas from other rodents. 
Etats are not infected directly by other rats but by means of their 
infected fleas. Bed -bugs may transmit the infection. 



ACTINOMYCOSIS 16? 

Incubation Period. — The incubation period is commonly from three 
to seven days, although occasionally prolonged to eight or even fourteen 
days. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the disease by the clinical symptoms, confirmed 
by bacteriological examination of blood, pus from glandular lesions, or 
sputum. Climatic bubo and venereal buboes are the diseases most 
apt to be mistaken for plague infection. 

2. Isolation of the patient in a hospital if practicable; if not, in a 
screened room which is free from vermin. In plague pneumonia, 
personal prophylaxis, to avoid droplet infection, must be carried out 
by persons who come in contact with the sick. Masks or veils of 
cheesecloth should be worn as protective measures. 

3. Immunization. — Passive immunization of known exposed con- 
tacts; active immunization of those who may be exposed. 

4. Quarantine of contacts for seven days. 

5. Concurrent disinfection of all discharges and articles freshly soiled 
therewith. 

At termination use thorough cleansing and disinfection. 

II. General Measures. — 1. Extermination of rats and vermin by use 
of known methods for their destruction; destruction of rats on ships 
arriving from infected ports; examination of rats, ground squirrels, 
etc., in areas where the infection persists, for evidence of endemic 
or epidemic prevalence of the disease among them. 

2. Supervision of autopsies of all deaths during epidemics. 

3. Cremation, or burial in quicklime, of those dying of this, disease. 



CLIMATIC BUBO. 

This is a disease of unknown etiology occurring in the West Indies 
and many tropical and subtropical countries. The inguinal glands 
are enlarged. The swelling is associated with moderate pain and 
fever. The duration of the disease is from two weeks to several 
months. Sailors and stokers are apt to contract it. The prognosis 
is always good. Relapses may occur. No methods of prevention are 
known. 

ACTINOMYCOSIS. 

This disease occurs endemically in cattle; it is more rare among 
swine and horses. Many cases have in recent years been reported 
in man. The disease is rarely communicated from one animal 
to another and no case is known of a direct history of human con- 
tagion. 

As a rule, the disease is not accompanied by fever. In cattle the dis- 
ease is usually situated in some portion of the head, especially in the 
jaw, tongue, or tonsils, hence called "lumpy jaw," "wooden tongue," 



168 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

etc. Primary lung, intestinal and skin lesions are not infrequent. 
These local lesions sometimes scatter and produce a general infection 
and the udder may be involved. 

Infectious Agent. — The infecting agent is the Actinomyces bovis. 

Source of Infection. — The source of infection is the nasal and bowel 
discharges, and the infected material from lesions in human and 
animal cases of the disease. Uncooked meat from infected animals 
may serve as a source of infection. 

Mode of Transmission. — The mode of transmission is by contact 
with the discharges or with articles freshly soiled with discharges from 
animal or human cases. 

Incubation Period. — The incubation period is unknown. 

Period of Communicability. — The period of communicability is as 
long as open lesions remain, as proved by the presence of infective 
agent on microscopic or cultural tests. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the disease by the clinical symptoms, confirmed by 
microscopic examination of discharges from lesions. 

2. Isolation. — None, provided the patient is under adequate medical 
supervision. 

3. Immunization. — None. 

4. Quarantine. — None. 

5. Concurrent disinfection of discharges from lesions and articles soiled 
therewith. 

6. Terminal disinfection by thorough cleansing. 

n. General Measures. — 1. Inspection of meat, with condemnation of 
carcasses, or infected parts of carcasses, of infected animals. 
2. Destruction of known animal sources of infection. 

GLANDERS. 

Glanders. — An infectious disease of the horse, communicated occa- 
sionally to man. In the horse it is characterized by the formation of 
nodules, chiefly in the nostrils (glanders) and beneath the skin (farcy) . 

Glanders is communicated to man by contact with affected animals, 
usually by inoculation on an abraded surface of the skin. The con- 
tagion may also be received on the mucous membrane. Infection has 
occasionally been produced in bacteriologic laboratories. In man, as 
in horses, an acute and chronic form of glanders may be recognized. 
It is transmissible also from man to man. Washerwomen have been 
infected from the clothes of a patient. Glanders is by no means an 
uncommon disease among horses, sometimes taking a mild course and 
remaining latent for a considerable time. Horses apparently healthy, 
therefore, may possibly spread the disease through the public drinking 
troughs and blacksmith shops. 

Infectious Agent. — The infectious agent is the Bacillus mallei. 

Source of Infection. — The source of infection is the discharges from 
open lesions of mucous membranes, or of the skin of human or equine 






ANTHRAX 169 

cases of the disease (i. e., pus and mucus from the nose, throat, and 
bowel discharges from infected man and horse). 

Mode of Transmission. — The mode of transmission is by contact with 
a case or with articles freshly soiled by discharges from a human or 
equine case. 

Incubation Period. — The incubation period is unknown. 

Period of Communicability. — The period of communicability is until 
bacilli disappear from discharges or until lesions have healed. 

Methods of Control. — I. The Infected Individual and his Environ- 
ment. — 1 . Recognition of the disease by specific biological reactions, such 
as the complement-fixation test, the mallein test, the agglutination 
test; or by non-specific reactions, such as the Straus reaction, if con- 
firmed by culture, or by identification of the Bacillus mallei, or by 
autopsy of doubtful cases. 

2. Isolation of human cases at home or in the hospital; for infected 
horses destruction rather than isolation is advised. 

3. Immunization. — None of established value or generally accepted. 

4. Quarantine of all horses in an infected stable until all have been 
tested by specific reaction, and the removal of infected horses and 
terminal disinfection of the stable have been accomplished. 

5. Concurrent disinfection of discharges from human cases and articles 
soiled therewith. 

6. Terminal disinfection of stables and contents in horse cases of 
the disease. 

II. General Measures. — 1. The abolition of the common drinking 
trough for horses. 

2. Sanitary supervision of stables and blacksmith shops. 

ANTHRAX. 

Anthrax (Malignant Pustule — Woolsorters' Disease). — An acute 
infectious disease which is very prevalent among animals, particularly 
sheep and cattle due to the Bacillus anthracis. It occurs in man 
sporadically as a result of accidental infection. 

This disease is the most widespread of all infectious disorders. It 
is much more common in Europe and in Asia than in America. The 
ravages among herds of cattle in Russia and Siberia, and among sheep 
in certain parts of France, Hungary, Germany, Persia and India exceed 
any other animal plague. In infected districts the greatest losses are 
incurred during the hot months of summer. Cold-blooded animals 
and birds as well as swine and dogs, are refractory. In this country 
the disease is rather rare. 

In man it occurs as the result of infection, either through the skin, 
the intestines, or in rare instances through the lungs. It is found in 
persons whose occupations bring them into contact with animals or 
animal products, as stablemen, shepherds, tanners, butchers, and 
those who work in wool and hair. Two forms of the disease have been 
described — the external anthrax or malignant pustule, and the internal 



170 PREVEXTION OF INDIVIDUAL INFECTIOUS DISEASES 

anthrax, of which there are intestinal and pulmonary forms, the latter 
being known as "woolsorters' disease." The malignant forms, par- 
ticularly the intestinal or pulmonary cases, are usually fatal. 

Source of Infection. — The source of infection is the hair, hides, flesh 
and feces of infected animals. Shaving brushes have been shown to 
be frequently infected. 

Mode of Transmission. — The mode of transmission is by inoculation, 
as by accidental wound or scratch, inhalation of spores of the infectious 
agent and ingestion of insufficiently cooked infected meat. 

Incubation Period. — The incubation period is within seven days. 

Period of Communicability. — The period of communicability is during 
the febrile stage of the disease and until lesions have ceased discharging. 
Infected hair and hides of infected animals may communicate the 
disease for many months after slaughter of the animal, and after the 
curing of hide, fur or hair unless disinfected. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the disease by the clinical symptoms, confirmed 
by bacteriological examination. 

2. Isolation of the infected individual until the lesions have healed. 

3. Immunization. — None. 

4. Concurrent disinfection of the discharges from lesions and articles 
soiled therewith. 

n. General Measures. — 1. Animals ill with a disease presumably 
anthrax should be placed immediately in the care of a veterinary 
surgeon and isolated. 

2. Immunization of exposed animals under direction of Federal or 
State Department of Agriculture. 1 

3. Postmortem examinations should be made only by a veterinary 
surgeon, or in the presence of one. 

4. Milk from an infected animal should not be used. 

5. Shaving and other brushes should only be made from uninfected 
or disinfected materials. 

G. Control and disinfection of effluent and trade wastes and of areas 
of land polluted by such effluent and wastes from factories or premises 
when spore-infected hides or other infected hide and hair products are 
known to have worked up into manufactured articles. 

7. A physician should be constantly employed by every company 
handling raw hides, or such companies should operate under the direct 
supervision of a medical representative of the health department. 

8. Every employee handling raw hides, hair or bristles who has an 
abrasion of the skin should immediately report to a physician. 

9. Special instruction should be given to all employees handling raw 
hides in regard to the necessity of personal cleanliness. 

10. Tanneries and woollen mills should be provided with proper 
ventilating apparatus so that dust can be promptly removed. 

1 1. Disinfection of hair, wool, and bristles of animals originating in 
known infected centers before they are used or assorted. 

1 Tho method of producing immunity to anthrax in cattle and sheep through the injec- 
tion of attenuated cultures, as suggested by Pasteur, is not applicable to man. 



ROCKY MOUNTAIN SPOTTED FEVER 171 

12. The sale of hides from an animal infected with anthrax should 
be prohibited. A violation of this regulation should be immediately 
reported to the State Commissioner of Agriculture, by telegram, stating 
the time, place, and purchaser to whom the hide was sold. The report 
should also be sent to the person purchasing the hide. Carcasses 
should be disposed of under the supervision of the State Department 
of Agriculture. The inspection and disinfection of imported hides are 
under the supervision of the United States Bureau of Animal Industry. 
In the event that infection is introduced the State Agricultural authori- 
ties have jurisdiction over infected animals and the local or State 
health authorities have jurisdiction over infected persons. 



ROCKY MOUNTAIN SPOTTED FEVER. 

An acute infectious disease characterized by fever and a more or 
less hemorrhagic eruption. 

This disease, also called tick and spotted fever, occurs chiefly in the 
Bitter Root Valley of Montana, and in the neighboring States of 
Idaho and Wyoming, also in Washington and California. The symp- 
toms resemble those of typhus fever. Ticks of the genus Dermacentor 
probably carry the infection. These ticks either in the miniature or 
adult stage have been found upon 20 species of 500 mammals examined 
in and around Bitter Root Valley. 

Infectious Agent. — The infectious agent is unknown. 

Source of Infection. — The source of infection is the blood of infected 
animals, and infected ticks (Dermacentor species). 

Mode of Transmission. — The mode of transmission is by the bites of 
infected ticks. 

Incubation Period. — The incubation period is from three to ten days, 
usually seven days. 

Period of Communicability. — The period of communicability has not 
been definitely determined, probably during the febrile stage of the 
disease. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the disease by the clinical symptoms in areas where 
the disease is known to be endemic. 

2. Isolation. — Xone other than care exercised to protect patients 
from tick bites when in endemic areas. 

3. Im m u n ization . — Xone. 

4. Quarantine. — Xone. 

5. Concurrent Disinfection. — Xone. All ticks on the patient should 
be destroyed. 

6. Terminal Disinfection. — Xone. 

n. General Measures. — 1. Personal prophylaxis of persons entering 
the infected zones during the season of ticks by wearing tick-proof 
clothing and careful daily search of the body for ticks which may have 
attached themselves. 



172 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

*_\ The destruction of ticks by clearing and burning vegetation on 
the land in infected zones. 

:>. The destruction of ticks on domestic animals by dipping, and the 
pasturing of sheep on tick-infected areas where the disease is prevalent, 
with the object of diminishing the number of ticks. 

4. The destruction of small mammalian hosts as ground squirrels, 
chipmunks, etc. 

DENGUE. 

Dengue ("Break-bone Fever"). — An acute infectious disease of 
tropical and subtropical countries, characterized by febrile paroxysms, 
pains in the joints and muscles, and sometimes a skin eruption. 

This disease occurs in widespread epidemics often preceding or 
coincident with those of yellow fever, which adds to its importance. 
It attacks all races equally, and although it is a painful affection and 
sometimes leaves the body in a weakened condition for a long time, it 
is never fatal. 

Infectious Agent. — The infectious agent is unknown. 

Source of Infection. — The source of infection is the blood of infected 
persons. 

Mode of Transmission. — The mode of transmission is by the bite of 
infected mosquitoes, probably the Culex fatigans. 

Incubation Period. — The incubation period is from four to five days. 

Period of Communicability. — The period of communicability is during 
the febrile stage of the disease. 

Methods of Control. — I. The Infected Individual and his Environ- 
ment. — 1. Recognition of the disease by the clinical symptoms. 

2. Isolation of the patient in a screened room. 

3. Immunization. — None. 

4. Quarantine. — None. 

5. Concurrent Disinfection. — None. 

6. Terminal Disinfection. — None. Upon the termination of the dis- 
ease, fumigation of the room and house, to destroy mosquitoes. 

II. General Measures. — These include measures directed toward 
elimination of mosquitoes, and screening of rooms. 

INFECTIOUS CUTANEOUS DISEASES CAUSED BY FUNGI. 

Tinea circinata or Ringworm of the body or hairless parts of the 
skin, and Tinea tonsurans, Tinea barbae or Tinea sycosis, ringworm of 
the hairy parts of the skin, are two species of the trichophyton. 

Ringworm of the skin yields readily to treatment, but ringworm of 
the scalp is extremely chronic. When the disease attacks the scalp 
the hair falls or breaks off near the scalp, leaving areas the size of a 
dime or dollar nearly bald. The scalp in these areas is usually dry and 
somewhat scaly, but may be swollen and crusty. The disease spreads 
at the circumference of the area and new areas are produced by 
scratching, etc. 






INFECTIOUS CUTANEOUS DISEASES CAUSED BY FUNGI 173 

Tinea favosa or Favus is a cutaneous disease somewhat allied to 
ringworm, though less contagious. It is caused by a fungus, the 
Achorion schoenleinii. 

In this disease abundant umbilicated crusts of yellowish color are 
present, when the process is active, which grow into a mass resembling 
a honeycomb. The disease is communicated by contagion, the fungus 
being often derived from animals, especially cats, mice, rabbits and 
fowls; dogs are also subject to it. It grows more slowly than the ring- 
worm fungus, and therefore is not so easily transmitted. Want of 
cleanliness is a predisposing factor. The fungus seems to find more 
favorable soil for its development in the skin of persons in delicate 
health, especially from phthisis, than in others. The disease shows a 
marked preference for the scalp, but no part of the skin is exempt. 
The roots of the hair are killed by the parasite, so that loss of hair from 
the disease is permanent , a scar remaining when the condition is cured. 

Tinea versicolor or Pityriasis versicolor is another parasitic skin 
disease. It is caused by the fungus, Microsyor on furfur. 

This disease by preference attacks the chest, abdomen, back and 
axillae, less frequently the neck and arms, while exceptionally it attacks 
also the head and face. The growth shows itself as scattered spots, 
varying in color from cream-coffee to reddish brown. The infection, 
though slightly contagious, is one of the most common of skin diseases. 
Persons with a tender skin.and a disposition to perspire freely are par- 
ticularly affected. Women are more frequently attacked than men, 
while children and old persons are rarely affected. The source of the 
affection is unknown, as absence of contagion has been repeatedly 
demonstrated. 

Infectious Agent. — The infectious agent is various forms of fungi: 

1. Tinea circinata and other forms of ringworm — trichophyton. 

2. Tinea favora (favus) — Achorion schoenleinii. 

3. Tinea versicolor — Microsporon furfur. 

Source of Infection. — The source of infection are lesions of the skin 
and scalp. 

Mode of Transmission. — The mode of transmission is by direct con- 
tact with the patient and indirectly through toilet articles. 

Incubation Period. — The incubation period is unknown. 

Period of Communicability. — The period of communicability is until 
the skin and scalp lesions are all healed. 

Methods of Control. — I. The Infected Individual and his Environ- 
ment. — 1. Recognition of the disease by its clinical symptoms, confirmed 
by microscopic examination of the lesions (crusts) . 

2. Isolation. — Exclusion of the patient from school and other public 
places until the lesions are healed. 

3. Immunization. — None. 

4. Quarantine. — None. 

5. Concurrent disinfection of the toilet articles of the patient. 

6. Terminal Disinfection. — None. 

II. General Measures. — 1. Elimination of common utensils, such as 
hair brushes and combs, etc. 



174 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

2. Provision for adequate and intensive treatment and care of cases 
of infectious skin diseases at hospitals and dispensaries, to alleviate 
the period of the infectivity of the patients. 

TRICHINOSIS. 

An infectious febrile disease caused by the Trichinella spiralis, a round 
worm which passes its entire life cycle in man, rat or hog. 

The incidence of this disease in swine varies much in different coun- 
tries according to the thoroughness with which systematic microscopic 
examination of swine flesh is made. About 1 or 2 per cent, of American 
swine and a larger percentage of American rats are infected. The 
normal or common host of the parasite is the rat, which becomes 
infected in slaughter houses and butcher shops. Hogs get the disease 
by eating rats, through feces or directly from infected ofTal. Man 
receives the infection by eating the uncooked or insufficiently cooked, 
flesh of trichinous hogs. 

The Trichinella spiralis in its adult condition lives in the small intes- 
tines. The disease is produced by the embryos, which pass from the 
intestines and reach the voluntary muscles, where they finally become 
encysted — muscle trichina?. It is in the migration of the embryos 
that the group of symptoms known as trichinosis is produced. 

Not all persons who eat trichinous flesh have the disease. When a 
limited number of the parasites are eaten only a few embryos pass to 
the muscles and may cause no symptoms. Well characterized cases 
in man present two stages: (1) gastro-intestinal, and (2) general 
infection. In the second stage the symptoms are fever, intense pain 
in the muscles, edema and leukocytosis. The average mortality of the 
disease is about half that of typhoid fever, in some epidemics rising 
to 16 or even 30 per cent. 

Infectious Agent. — The infectious agent is the Trichinella spiralis. 

Source of Infection. — The source of infection is uncooked or insuffi- 
ciently cooked meat of infected hogs. 

Mode of Transmission. — The mode of transmission is the consumption 
of undercooked infected pork products. 

Incubation Period. — The incubation period is variable, usually about 
one week. 

Period of Communicability. — The disease is not transmitted by the 
human host. 

Methods of Control. — I. The Infected Individual and his Environ- 
ment. — 1. Recognition of the disease by the clinical symptoms, confirmed 
by microscopic examination of muscle tissue containing trichinae. 

2. Isolation. — None. 

: ;. / /// /// // // ization . — None. 

4. Quarantine. — None. 

."). Concurrent Disinfection. — Sanitary disposal of the feces of the 
patient. 

6. Terminal Disinfection, — None, 






ANCHYLOSTOMIASIS 175 

n. General Measures. — 1. Inspection of pork products for the detec- 
tion of trichinosis. 

2. Thorough cooking of all pork products at a temperature of 160° F. 
or over. 

3. Persistent warfare against rats in slaughter houses, butcher shops, 
markets and places where hogs are kept. 

•4. Contaminated feces and offal must not be fed to hogs. 

ANCHYLOSTOMIASIS. 

Hookworm disease is endemic in tropical and subtropical countries 
encircling the globe, but diminishing toward the temperate regions. 
It does not occur in the colder latitudes, except in mines, especially 
those of Wales, Germany, Netherlands, Belgium, France and Spain. 
The Egyptian chlorosis, brickmakers' anemia, tunnel anemia, miners' 
cachexia and mountain anemia are due to this cause. Hookworm 
disease is very common in American Samoa and in Porto Rico, also 
in Southern China, India and Egypt. In this continent a large number 
of the population among the poorer classes are infected in the Southern 
States from the Potomac to the Mississippi and along the Atlantic 
Seaboard and the Gulf States. 

There is no acquired immunity to the disease, although there is a 
distinct racial immunity, as shown in the negroes and Filipinos, who 
are often infected but have comparatively slight symptoms. It is 
thought that the negro is the original source, as he is the chief reservoir 
of the infection in this country, having brought it from Africa, where 
he had the disease so many generations ago that he has become immune. 

Hookworm disease is much more serious in its secondary results than 
in its primary effects; it lowers the resistance and greatly increases the 
liability to other infections, especially tuberculosis. Its prevention, 
therefore, presents a problem of considerable importance from a public 
health standpoint. 

Almost all m amm alian animals have hookworms, but each host has 
a species peculiar to itself and specific for each. Thus the hookworm 
of the dog differs from that of man and other mammalian hosts and 
will not infect them. 

There are two species found in man, but the vast majority of cases 
of hookworm disease in man in the United States are due to the Xecator 
americanus. In 90 per cent, or more of cases the infection is com- 
municated through the skin at any point, but the embryos usually 
enter the soft skin between the toes of persons who go barefoot on 
polluted soil. The embryos may also occasionally be taken in by the 
mouth in drinking water or solid food, or from contaminated objects, 
such as dirty fingers. 

The hookworm larva passes through five molts, two of which occur 
during its free-living stage in the outer world and three dining its 
residence in the host. With each stage it approaches nearer to the 
appearance and structure of the adult worm. The larva pierces the 



176 PREVENTION OF INDIVIDUAL INFECTIOUS DISEASES 

skin and passes by a circuitous route to the intestinal tract. In its 
passage through the skin (as between the toes) it produces an inflam- 
matory reaction known as ground-itch. The infection leaves the body 
exclusively in the feces, which contain the eggs of the parasite. 

Infectious Agent. — The infectious agent is the achylostoma (Necator 
americanus). 

Source of Infection. — The source of infection is the feces of infected 
persons. Infection generally takes place through the skin, occasionally 
by the mouth. 

Mode of Transmission. — The mode of transmission is by drinking 
water containing larvae, by eating soiled food, by hand to mouth tran- 
mission of the eggs or larvae from objects soiled with infected discharges. 
The larval forms pierce the skin and passing through the lymphatics 
to the vena cava and the right heart, thence in the blood stream to the 
lungs, they pierce the capillary walls and pass into the alveoli. Then 
they pass up the bronchi and trachea to the throat, whence they are 
swallowed and finally lodge in the small intestine. 

Incubation Period. — The incubation period is from seven to ten weeks. 

Period of Communicability. — The period of communicability is as 
long as the parasite or its ova are found in the bowel discharges of an 
infected individual. Contaminated soil remains infective for five 
months in the absence of freezing. 

Methods of Control. — I. The Infected Individual and his Environment. 
— 1. Recognition of the disease by microscopic examination of bowel 
discharges. 

2. Concurrent Disinfection. — Sanitary disposal of bowel discharges. 

3. Treatment. — Appropriate treatment (by the use of thymol, beta- 
naphthol or other anthelmintic) of infected individuals to rid the intes- 
tinal canal of the parasite and its ova. 

n. General Measures. — 1. Education as to the dangers of soil pollution. 

2. Prevention of soil pollution by installation of sanitary disposal of 
human discharges. 

3. Personal prophylaxis by cleanliness and the wearing of shoes. 



CHAPTER IV. 

PRACTICAL USE OF DISINFECTANTS. 

By WILLIAM H. PARK, M.D. 

Many substances, when brought in contact with bacteria, combine 
with their cell substance and destroy the life of the bacteria. While 
in the vegetative stage bacteria are much more easily killed than when 
in the spore form, and their life processes are inhibited by substances 
less deleterious than those required to destroy them. 

Bacteria, both in the vegetative and in the spore form, differ among 
themselves considerably in their resistance to the poisonous effects of 
chemicals. The reason for this is not wholly clear, but it is connected 
with the structure and chemical nature of their cell substance. 

Chemicals in sufficient amount to destroy life are more poisonous 
at temperatures suitable for the best growth of bacteria than at lower 
temperatures, and act more quickly upon bacteria when they are sus- 
pended in fluids singly than when in clumps, and in pure water rather 
than in solutions containing organic matter. The increased energy of 
disinfectants at higher temperatures indicates in itself that a true 
chemical reaction takes place. In estimating the extent of the destruc- 
tive or inhibitive action of chemicals the following degrees are usually 
distinguished : 

1. The growth is not permanently interfered with, but the pathogenic 
and zymogenic functions of the organism are diminished — attenuation. 
This loss of function is usually quickly recovered. 

2. The organisms are not able to multiply, but they are not destroyed 
— antiseptic action. When transferred to a suitable culture fluid free 
of the disinfectant these bacteria are capable of reproduction. 

3. The vegetative development of the organisms is destroyed, but 
not the spores — incomplete or complete sterilization or disinfection, 
according as to whether spores are present in the organisms exposed 
and as to whether these spores are capable of causing infection. 

4. Vegetative and spore forms are destroyed. This is complete 
sterilization or disinfection. 1 

A deodorant destroys or neutralizes unpleasant odors. Many 
deodorants have no disinfecting power. Fumigation is the use of 
fumes or gases, driven off by heat, or other means. Some of these gases 
destroy bacteria, others, vermin and insects. Many are very poison- 
ous to the higher forms of life. Lender ordinary conditions gases 
have great difficulty in penetrating substances. A moderately high 
temperature aids penetration. 

1 Disinfection strictly defined is the destruction of all organisms and their products 
which are capable of producing disease. Sterilization is the destruction of all saprophytic 
as well as parasitic bacteria. It is not necessary in most cases to require disinfectants 
to be capable of sterilizing infected materials containing spores, for there are but few 
varieties of pathogenic bacteria which produce spores, 
12 



ITS PRACTICAL USE OF DISINFECTANTS 

Insecticides. — Gases which act on insects are called insecticides. 
Some act by suffocation, some as general tissue poisons and some 
especially on the nervous system. 

The methods employed for the determination of the germicidal action 
of chemical agents on bacteria are, briefly, as follows: 

If it is desired to determine the minimum concentration of the chemical 
substance required to produce complete inhibition of growth we proceed 
thus: A 10 per cent, solution of the disinfectant is prepared and 1 c.c, 
0.5 c.c, 0.3 c.c, etc., of this is added to 10 c.c of liquefied gelatin, agar, 
or bouillon, or, more accurately 10 c.c. minus the amount of solution 
added, in so many tubes. The tubes then contain 1 per cent., 0.5 per 
cent., 0.3 per cent., and 0.1 per cent, of the disinfectant. The fluid 
medium in the tubes is then inoculated with a platinum loopful of the 
test bacterium. The melted agar and gelatin may be simply shaken 
and allowed to remain in the tubes, and watched for any growth which 
takes place, or the contents of the tubes may be poured into Petri 
dishes, where the development or lack of development of colonies and 
the number can be observed. If no growth occurs in any of the dilutions, 
lower dilutions are tested. Bacteria that have been previously injured 
in any way will be inhibited by much weaker solutions of chemicals 
than will vigorous cells. The same test can be made with material 
containing only spores. 

If it is desired to determine the degree of concentration required for 
the destruction of vegetative development, the organism to be used 
is cultivated in bouillon, and into each of a series of tubes is placed a 
definite amount of diluted culture from which all clumps of bacteria 
have been filtered; to these a definite amount of watery solution of 
different percentages of the disinfectant is added. At intervals of one, 
five, ten, fifteen, and thirty minutes, one hour, and so on a small platinum 
loopful of the mixture is taken from each tube and inoculated into 10 
c.c. of fluid agar or gelatin, from which plate cultures are made. When- 
ever it is probable that the antiseptic power of the disinfectant ap- 
proaches somewhat the germicidal, it is necessary to inoculate a second 
series of tubes from the first so as to decrease still further the amount of 
antiseptic carried over. The results obtained are signified as follows : x 
per cent, of the disinfectant in watery solution and at y temperature kills 
the organism in twenty minutes, z per cent, at the same temperature kills 
in one minute, and so on. If there be any doubt whether the trace of the 
disinfectant carried over with the platinum loops may have rendered the 
gelatin unsuitable for growth, thus falsifying results, control cultures, if 
extreme accuracy is desired, should be made by adding bacteria which 
have been somewhat enfeebled by slight contact with the disinfectant to 
fluid to which a similar trace of the disinfectant has been added. If the 
strength of the disinfectant is to be tested for different substances it must 
be tested in these substances or their equivalent, and not in water. 

The disinfectant to be examined should always be dissolved in an 
inert fluid, such as water; if on account of its being insoluble in water it 
is necessary to use another solvent, control experiments may be required 
to determine its action on the organism. Sometimes, as in the case of 
corrosive sublimate, the chemical unites with the cell substance to form 



STANDARDIZATION OF DISINFECTANTS 



179 



an unstable compound, which inhibits the growth of the organism for a 
time before destroying it. If this compound is not broken up in the 
media it will probably not be in the body. In some tests it is of interest 
to break up this union and note then whether the organism is alive or 
dead. With corrosive sublimate the bacteria probably die within thirty 
minutes after the union occurs. 

In the above determinations the absolute strength of the disinfectant 
required is considerably less when culture media poor in albumin are 
employed than when the opposite is the case Cholera spirilla grown 
in bouillon containing no peptone or only 0.5 per cent, of peptone are 
destroyed in half an hour by 0.1 per cent, of hydrochloric acid; grown 
in 2 per cent, peptone bouillon, their vitality is destroyed in the same 
time on the addition of 0.4 per cent. HC1. In any case the organisms 
to be tested should all be treated in exactly the same way and the 
results accompanied by a statement of the conditions under which the 
tests were made. It is becoming the custom to state the power of a 
disinfectant in terms of comparison with pure carbolic acid. A sub- 
stance which had the same destructive power in a 1 to 1000 solution 
as carbolic acid in a 1 to 100 solution would be rated as of a strength 
ten times that of carbolic acid. 

The following table gives the results and methods used in an actual 
experiment to test the effect of blood serum upon the disinfecting action 
of bichloride of mercury and carbolic acid upon bacteria. 



Test for the Difference 
Acid Solution on 


of Effect of Bichloride of Mercury and Carbolic 
Typhoid Bacilli in Serum and in Bouillon. 


Time. 


1' 


3' 


5' 


10' 


20' 


30' 


45' 


1 

hr. 


K 1§ 

nrs. 


2 
hrs. 


Strength of 
solution. 


A. serum . . 2.5 c.c. 1 
HgChsol. 1:1000 2.5 c.c. [ 
Typhoid broth culture J 

B. bouillon . 2.5 c.c. 
HgChsol. 1:1000 2.5 c.c. • 
Typhoid broth culture 

C. serum . . 2.5 c.c. 1 
Carbolic sol. 5% 2.5 c.c. [■ 
Typhoid broth culture J 

D. bouillon . 2.5 c.c. ) 
Carbolic sol. 5% 2.5 c.c. Y 
Typhoid broth culture J 


+ 

+ 
+ 


+ 
+ 


+ 
















(Equals 1:2000 
\ bichloride. 

Same. 

f Equals 2\% 
\ carbolic acid. 

Same. 



— Indicates total destruction of bacteria with no growth in media. 
+ Indicates lack of destruction of bacteria with growth in media. 



THE STANDARDIZATION OF DISINFECTANTS. 

Rideal and Walker were the first to urge a useful method for stand- 
ardizing disinfectants. 

In carrying out the test the various factors must be carefully con- 
trolled, thus: Time: this should be constant, the strength of the 
disinfectant being the variant. Test organisms: a standard culture of 
the typhoid bacillus (Hopkins' strain) is used to avoid any variations 



ISO 



PRACTICAL USE OF DISINFECTANTS 



due to the different degrees of resistance of various strains. The culture 
should be subinoculated three days before used. Medium: a standard 
meat-extract broth 1.5 per cent, acid to phenolphthalein; 10 c.c. to a 
tube is employed. Temperature: this test is done at 20° C. This is 
important, as the germicidal activity increases with the temperature. 
Constant amount of culture used: 0.1 c.c. of the twenty-four-hour broth 
culture is added to 5 c.c. of the disinfectant solution. This is more 
accurate than the drop method. Amount inoculated: it is essential 
that the same amount be inoculated from each dilution. Platinum 
loops made of 23 United States gauge wire, the loops being 4 mm. in 
diameter are employed. Several are used, being left on a rack after 
sterilization so»as to be cold when needed. The loop is bent at an angle 
of 45° to the shank. 

The actual test is carried out as follows : A 5 per cent, carbolic solu- 
tion (phenol C. P.), is prepared and standardized by bromine titration. 
From this freshly prepared 1 to 90 to 1 to 100 and 1 to 110 dilutions 
are made as needed. The necessary dilutions of germicide are then 
prepared. Wide jumps in the dilutions are made in the first test and 
then narrowed as the limits of the disinfectant are determined. 

Five test-tubes are arranged in a row in a water-bath at 20° C, and 
the solutions added in 5 c.c. amounts. Time must be allowed for the 
solution to reach 20° C. If the bath be large enough, little attention 
is needed to keep the temperature constant. The culture having been 
brought to 20° C, is then added in 0.1 c.c. amounts and the tubes shaken, 
an interval of thirty seconds allowed between each tube. Subinocula- 
tion of the first tube is then made after thirty seconds, which gives an 
interval of two and a half minutes after inoculation. The tubes are 
then subinoculated in order at thirty-second intervals, giving an 
interval for each of two and one-half minutes after inoculation, and 
starting at the first, gives an interval of five minutes, etc. 

It is possible to use ten tubes, as each step can be done in less than 
fifteen seconds if properly arranged, allowing a much wider range for 
each test. It is not necessary to keep the cotton plugs in the tube 
during the operation nor to remove the tubes from the bath to obtain 
the loopful for inoculation. The loop is plunged to the bottom, care 
being taken not to touch the sides of the tubes, and care should also be 
taken that a loopful is carried away each time. The broth tubes are 
incubated for forty-eight hours and then examined for growth. 

The following are given as two examples: 











Time of exposure: 










2.5 


5 


7.5 


10 


12.5 


15 


Phenol 


Sample. 


Dilution. 


min. 


min. 


min. 


min. 


min. 


min. 


coefficient. 


Phenol . . 


. 1 to 90 


+ 


— 


— 


— 


— 


— 


100)550 




1 to 100 


+ 


+ 


+ 


- 


- 


-. 


5.5 


Disinfectant A 


. 1 to 450 


+ 


+ 


_ 





_ 









1 to 550 


4- 


+ 


+ 


— 


_ 


_ 






1 to 600 


+ 


+ 


+ 


+ 


- 


- 




Phenol . . 


. 1 to 100 


+ 


+ 


+ 


_ 


_ 


_ 


110)650 




1 to 110 


+ 


+ 


+ 


+ 


+ 


- 


5.191 


Disinfectant A 


. 1 to 600 


+ 


+ 


+ 


+ 





, 






1 to 650 


+ 


+ 


+ 


+ 


+ 


_ 






1 to 700 


+ 


+ 


+ 


. + 


+ 


+ 





STANDARDIZATION OF DISINFECTANTS 



181 



These tables not only serve as an example, but also show that unless 
many repetitions of the tests are made and averaged, considerable 
variations in the results may be obtained. A report of 5.5 or 5.1 is 
equally accurate in the test here reported of the R ideal-Walker method, 
even with certain improvements added. With practice, and by selection 
of the dilutions to be employed, the operator evidently can regulate 
the time factor so that fairly uniform results are obtainable. On the 
other hand, it not infrequently happens that if more than one carbolic 
dilution is employed, more than one time period is open to comparison. 
For these reasons Anderson and McClintic have modified the test by 
setting two time limits two and one-half and fifteen minutes and taking 
the average. The following is an example: 











Time 


of exposure. 










2.5 


5 


7.5 


10 


12.5 


15 


Phenol 


Sample. 


Dilution. 


min. 


min. 


min. 


min. 


min. 


min. 


coefficient. 


Phenol . . 


. 1 to 80 


- 


— 


- 


- 


- 


- 


375 650 




1 to 90 


+ 


— 


— 


— 


- 


— 


80 110 




1 to 100 


+ 


+ 


+ 


— 


— 


— 






1 to 110 


+ 


+ 


+ 


+ 


+ 


— 




Disinfectant A 


. 1 to 350 


_ 


_ 


_ 












1 to 375 


- 


- 


- 






4.69 + 5.91 




1 to 400 


+ 


— 


— 


— 






= 5. 




1 to 425 


+ 


+ 


— 


— 


— 


— 


2 




1 to 450 


+ 


+ 


— 


— 


— 


— 






1 to 500 


+ 


+ 


— 


— 


— 


— 






1 to 550 


+ 


+ 


+ 


— 


— 


— 






1 to 600 


+ 


+ 


+ 


+ 


— 


— 






1 to 650 


+ 


+ 


+ 


+ 


+ 


— 






1 to 700 


+ 


+ 


+ 


+ 


+ 


+ 


. 




1 to 750 


+ 


+ 


+ 


+ 


+ 


+ 





Disinfectants vary widely in their germicidal properties, depending 
on whether organic matter is present or not. As under practical condi- 
tions organic matter is usually present, it is of some importance to 
know how far organic matter decreases the efficiency. 

For the purpose of ob taming comparable results, Anderson and 
McClintic have suggested the use of peptone 10 per cent, and gelatin 
5 per cent, in distilled water. One part of the culture is mixed with 
10 parts of the organic solution, 1.1 c.c. being then added- to a series 
of dilution tubes containing 4 c.c. In determining the coefficient allow- 
ance must be made for the added amount of organic matter. 

The modified methods of Anderson and McClintic 1 are called the 
"hygienic laboratory phenol coefficient," with or without organic 
matter. Any organic matter may be used in the test to approach the 
special conditions under which a disinfectant is to be used. 

In comparing the value of disinfectants the cost as well as the 
coefficient must be considered. This is best stated in terms of the 



1 See Hygienic Laboratory Bulletin No. 82, for further details and apparatus for sim- 
plifying the steps of the test. 



182 



PRACTICAL USE OF DISINFECTANTS 



relative cost of 100 units of efficiency as compared with pure phenol 
100, thus: 



Cost of disinfectant per gallon 



( = Cost ratio) 



Coefficient of disinfectant 



; of phenol per gallon Coefficient of phenol (1). 

( = the efficiency), X 100 = relative cost per 100 units. 

Antiseptic Value. — With certain disinfectants there is sufficient of 
the disinfectant carried over by the loop to exert antiseptic action 
and growth does not occur. If this is not taken into consideration a 
disinfectant will be given an excessively high coefficient. No satisfac- 
tory method has been devised to avoid this difficulty. The inoculated 
broth tube may be shaken and a loop or more inoculated from it to 
second broth tube, in this way diluting the disinfectant still further. 

Chick 1 has attempted to overcome the difficulty in the case of mercury- 
containing disinfectants by adding 0.2 c.c. of a saturated watery solution 
of hydrogen sulphide to each tube of broth. 

Many substances which are strong disinfectants become altered 
under the conditions in which they are used, so that they lose a portion 
or all of their germicidal properties; thus, quicklime and milk of lime 
act by means of their alkali and are disinfecting agents only so long 
as sufficient calcium hydroxide is present. If this is changed by the 
carbon dioxide of the air into carbonate of lime it becomes harmless. 
Bichloride of mercury and many other chemicals, form compounds 
with many organic and inorganic substances, which, though still germi- 
cidal, are much less so than the original substances. Solutions of 
chlorine, peroxides, etc., when in contact with an excess of organic 
matter soon become inert because of the chemical compounds formed. 

Thymol and eucalyptol have about one-fourth the strength of car- 
bolic acid (Behring) . 

Oil of peppermint in 1 to 100 solution prevents the growth of bacteria. 

Tables of Antiseptic Values. 2 



Alum 


1 to 222 


Mercuric chloride 


1 to 14,300 


Aluminum acetate 


1 to 6000 


Mercuric iodide . 


1 to 40.000 


Ammonium chloride . 


1 to 9 


Potassium bromide . 


1 to 10 


Boric acid .... 


1 to 143 


Potassium iodide 


1 to 10 


Calcium chloride . 


1 to 25 


Potassium permanganate 


1 to 300 


Calcium hypochlorite 


1 to 1000 


Pure formaldehyde . 


1 to 25,000 


Carbolic acid .... 


1 to 333 


Quinine sulphate 


1 to 800 


Chloral hydrate . 


1 to 107 


Silver nitrate .... 


1 to 12,500 


Cupric sulphate . 


1 to 2000 


Sodium borate 


1 to 14 


Ferrous sulphate . 


1 to 200 


Sodium chloride . 


1 to 6 


Formaldehyde (40 per cent.) 


1 to 10,000 


Zinc chloride .... 


1 to 500 


Hydrogen peroxide . 


1 to 20,000 


Zinc sulphate 


1 to 20 



1 Journal of Hygiene, 1908, viii, 654. 

2 These figures are approximately correct, and represent the percentage of disinfection 
required to be added to a fluid containing considerable organic material, in order perma- 
nently to prevent any bacterial growth. Solutions of half the given strength will inhibit 
the growth of most bacteria and prevent the growth of many varieties. 



STANDARDIZATION OF DISINFECTANTS 



183 



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184 PRACTICAL USE OF DISINFECTANTS 

Practical Application of Disinfection. — It is best applied at the 
source of infection. The excretion of the patient, especially those 
from the month, nose and bowels, most frequently need disinfect- 
ion. When proper measures have been taken at the bedside to 
prevent the spread of infection in a case of typhoid fever or diphtheria, 
subsequent disinfection of the sick room will not be necessary, but 
when there is any doubt of diffusion of the infection, then a general 
disinfection is advisable. 

It is equally important to know how and what to disinfect as when 
and where to disinfect. No one should attempt to disinfect any 
given place unless he is familiar with the peculiarities of the particular 
infection with which he has to deal and has a thorough knowledge 
of the disinfecting agents employed. Personal attention to minute 
details is also necessary to secure success in disinfection. The mate- 
rials, the strength of solutions, modes of application, effect of tem- 
perature, humidity, outside winds, porosity of walls, shape and size 
of enclosures, etc., must be thoroughly understood, in order to obtain 
the best results. As a guide and check to the thoroughness of the 
process, and the degree of penetration, every gas disinfection should 
be controlled. This may be done by saturating threads with an 
active culture of Bacillus pyocyaneus, which are enclosed in thin 
paper envelopes and exposed in various parts of the room to be dis- 
infected. These threads, at the end of the operation, are dipped 
into Dunham's peptone solution, when, if the controls have survived, 
this is shown by the characteristic green coloration in the medium. 

Terminal Disinfection.— This has largely been dispensed with. 
The reasons are, because it has little effect upon the control of the 
communicable diseases, and because the cost of such fumigation 
appears to be disproportionately large to the results obtained. It 
is much more important to destroy the infective discharges through- 
out the course of the disease than to trust to one final disinfection 
of the sick-room and its contents. Fomites are now known to play 
a comparatively minor role in the spread of infection. The principal 
objects that need disinfection are the discharges from the body : towels, 
beddings, handkerchiefs and clothing; food; tableware and other 
objects that have been used by the patient in eating and drinking; 
and finally the hands of the nurse, physicians and others who come 
in contact with the infection. Terminal disinfection, however, would 
still seem to be worth while, if it prevents the occurrence of only a 
small number of cases. Terminal fumigation for measles, scarlet 
fever and certain other short-lived viruses may not be necessary, but 
disinfection of objects likely to convey disease will always be required. 

Penetration. — Most disinfectants have but little power of pene- 
tration. Substances in solution penetrate better than those in emul- 
sion. Gaseous substances cannot be depended upon to penetrate 
beyond one or two thicknesses of cloth unless aided by heat, their 
action being only on the surface. The most difficult objects to pene- 
trate, and at the same time the most important as usually containing 
virulent pathogenic microorganisms throughout their mass, are feces 



PRACTICAL DISINFECTION AND STERILIZATION 185 

and sputum. Such substances, therefore, must be thoroughly disin- 
tegrated and the disinfectant incorporated throughout the mass in 
order to permeate it in a reasonable time. In certain instances 
dependence should be placed only in steam, dry heat, or boiling, to 
effect necessary penetration. Upholstered furniture, mattresses, pil- 
lows, thick blankets and the like, cannot be penetrated by any of the 
ordinary chemical disinfectants. The bacteria that remain alive in 
them are probably safely held prisoners. 

The albuminous matter in which bacteria are usually embedded 
naturally seriously interferes with the efficiency of all disinfectants. 
Chlorinated lime and permanganate of potassium actively attack 
albuminous matter and are thus soon reduced. Formaldehyde and 
carbolic acid show less reduction of power in the presence of albuminous 
matter than perhaps any other disinfectant. 

Time is a very important element in disinfection. Even in moder- 
ately strong solutions and under favorable conditions, very few chemi- 
cal disinfectants act instantly. It is not enough to simply dip the 
hands in and out of a bichloride solution, to rinse fabrics in carbolic 
acid solution, or to pour formalin over feces. It takes time to pene- 
trate and then to destroy the life of the germs after the disinfectant 
comes in direct contact with it. 

In applying any disinfecting agent enough of the substance must be 
used so that the proportion required shall be present throughout the 
whole mass in the right dilution This is particularly important in 
the disinfection of urine, feces, sputum and the like. 

Choice of Disinfectants. — The choice of the chemical to be used 
depends somewhat on the nature of the substance to be disinfected, 
as well as upon the resistance of the bacteria or virus. For instance, 
ordinary germicidal solutions such as bichloride of mercury, 1 to 1000, 
or carbolic acid, 2\ per cent., cannot be trusted to kill tetanus spores; 
emulsions are not serviceable for the disinfection of feces; a weak 
chlorinated lime will disinfect water, but a strong solution is necessary 
to disinfect fabrics, but the strong solution bleaches and rots the fiber. 
Certain chemicals have a selective action and appear to be specific 
poisons for some organisms as, for example, copper sulphate for alg?e. 
On the other hand, carbolic acid is ineffective against the virus of small- 
pox. The choice of the chemical, therefore, its strength, and time of 
application, the temperature of the solution, and its method of employ- 
ment, are all problems which must be solved for each particular class 
of infection, and each particular group of substances. 

PRACTICAL DISINFECTION AND STERILIZATION (HOUSE, PERSON, 

INSTRUMENTS, AND FOOD). STERILIZATION OF MILK FOR 

FEEDING INFANTS. 

Disinfectants and Methods of Disinfection Employed in the House 
and Sickroom. — Disinfection and Disinfectants. — Sunlight, pure air, 
and cleanliness are always very important agents in maintaining 



186 PRACTICAL USE OF DISINFECTANTS 

health and in protecting the body against many forms of disease. 
When, however, it becomes necessary to guard against such special 
dangers as infectious material from communicable diseases the addi- 
tional protection of disinfection must be resorted to. Sunlight 
destroys only what it reaches and absolute removal of infectious 
material is difficult to attain and to be certain of. In order that 
disinfection shall afford complete protection it must be thorough; and 
an attempt at perfect cleanliness is better, even in the presence of con- 
tagious disease, than filth with incomplete disinfection. 

As few articles as possible should be exposed to the germs causing 
the communicable disease, for they may become carriers of infection. 
It is important, therefore, when conditions allow it, that all articles 
not absolutely necessary for the care and comfort of the sick person, 
especially upholstered furniture, carpets and curtains, should be removed 
from the room before placing the patient in it. 

Agents for Cleansing and Disinfection. — Too much emphasis cannot 
be placed upon the importance of cleanliness, both as to the person 
and the dwelling, in protecting the body from all kinds of infectious 
diseases. Sunlight and fresh air should be freely admitted, and per- 
sonal cleanliness should be attained by frequently washing the hands 
and body, replacing fabrics infected by expectoration, bowel discharges, 
etc. By these means most of the bacteria are removed. 

Cleanliness in dwellings, and in all places w r hich men frequent, 
may ordinarily be maintained by the use of the two following solutions : 

1. Soapsuds Solution. — For simple cleansing, or for cleansing after 
the methods of disinfection by chemicals to be described, one ounce 
of common soda should be added to twelve quarts of hot soapsuds 
(soft soap and water.) 

2. Strong Soda Solution. — For a stronger and more effective cleans- 
ing solution, which is also a fairly efficient disinfectant, dissolve one- 
half pound of common soda in three gallons of hot water. The 
solution thus obtained should be applied by scrubbing with a hard 
brush. 

When it becomes necessary to prevent the spread of communicable 
diseases by killing the living germs which cause them, more powerful 
agents must be employed than those required for simple cleanliness, 
namely, disinfectants. The following • are some of the most reliable 
disinfectants: 

1 . Heat. — Complete destruction by fire is an absolutely sane method of 
disposing of infected articles of little value, but continued high tem- 
peratures not so high as to injure most materials will also destroy all 
life. Thus, boiling or steaming in closed vessels for ten minutes will 
destroy all disease germs except those containing the most resistant 
spores. Dry heat at 150° C. will destroy vegetative forms in a few 
minutes and spores in from one to two hours. 

2. Carbolic Acid Solution. — Pure carbolic acid (phenol) crystallizes 
in long, colorless crystals, deliquesces in contact with air, and has a 
penetrating odor and burning taste. It is a corrosive poison. It dis- 



PRACTICAL DISINFECTION AND STERILIZATION 187 

solves in water with some difficulty and should be thoroughly mixed, 
therefore. It is not destructive to fabrics, colors, metals, or wood, and 
does not combine as actively with albuminous matters as bichloride of 
mercury. It is thus more suitable for the disinfection of feces. The 
cost of pure carbolic acid solutions is much greater than that of most 
of the other disinfecting solutions but except for disinfections of the 
skin, which in some persons it irritates, it is generally to be preferred 
by those not thoroughly familiar with disinfectants, as it does not 
deteriorate and is rather more uniform in its action than some of the 
other agents. 

To prepare carbolic acid solution dissolve six ounces of carbolic acid 
in one gallon of hot water (200 grams in 4000 c.c.) . This makes approxi- 
mately a 5 per cent, solution, which, for most purposes, may be diluted 
with an equal quantity of water. The commercial "soluble crude 
carbolic acid,'" which is cheaper and twice as effective as the pure 
carbolic acid, can be used for privies and drains. It makes a white 
emulsion on account of its not entering readily into solution. Care 
must be taken that the pure acid does not come in contact with the 
skin. 

3. Bichloride Solution. — Bichloride of mercury or corrosive sub- 
limate is one of the most powerful germicides. This substance, which 
dissolves in 16 parts of cold water, when present in 1 part in 100,000 
in nutrient gelatin or bouillon, inhibits the development of most 
bacteria. In water 1 part in 50,000 will kill many varieties in a few 
minutes, but in bouillon twenty-four hours may be needed. Many 
spores are killed in 1 to 500 watery solution within one hour. Corrosive 
sublimate is less effective as a germicide in alkaline fluids containing 
much albuminous substance than in watery solution; precipitates of 
mercury are found which are at first insoluble, so that a part of the 
mercury salts does not exert any action. For ordinary use, solutions 
of 1 to 500 and 1 to 2000 will suffice, when brought in contact with 
bacteria in that strength, to kill the vegetative forms within one to 
twenty minutes, the stronger solution to be used when much organic 
matter is present. 

To prepare bichloride solution dissolve sixty grains of pulverized 
corrosive sublimate and two tablespoonfuls of common salt in one 
gallon of hot water. This solution, which is approximately 1 to 1000, 
must be kept in glass, earthen, or wooden vessels (not in metal recep- 
tacles) . For safety it is well to color the solution. 

Both the carbolic and bichloride solutions are very poisonous when 
taken by the mouth, but are harmless when used externally. The 
disadvantages of the bichloride solution are that it corrodes metals, 
irritates the skin in strong solution, and forms almost inert compounds 
with albuminous matter. 

4. Milk of Lime. — Calcium hydroxide is a powerful disinfectant; the 
carbonate, on the other hand, is almost without effect. Milk of lime 
is made by adding one quart of dry, freshly slaked lime (calcium 
hydroxide) to four or five quarts of water. The lime is slaked by 



L88 PRACTICAL USE OF DISINFECTANTS 

pouring a small quantity of water on a lump of quicklime. The lime 
becomes hot, crumbles, and as the slaking is completed a white powder 
results. This powder is used to make milk of lime. Air-slaked lime 
(the carbonate) has no value as a disinfectant. A 1 percent, solution 
of calcium hydroxide kills bacteria which are not in the spore form 
within a few hours. A 20 per cent, solution added to equal parts of 
feces or other filth and mixed thoroughly will completely sterilize 
them within two hours. 

5. Dry Chlorinated Lime or so-called "Chloride of lime!' — It should 
not contain less than 10 per cent, of available chlorin, and can now be 
obtained containing 30 per cent. It should have a strong, pungent 
odor of chlorine. Its efficacy depends on the chlorine it contains in 
the form of hypochlorite of lime. A solution in water of 0.5 to 1 per 
cent, of chlorinated lime will kill most bacteria in one to five minutes, 
and 1 part in 100,000 will destroy typhoid bacilli in twenty-four hours. 
A 5 per cent, solution usually destroys spores within one hour. Chlori- 
nated lime not only bleaches, but destroys fabrics. It must be fresh 
and kept in closed vessels or packages. 

Labarraqnes solution of the hypochlorites is practically the same as 
chlorinated lime and is much more expensive. 

('). Formalin. — This is a watery solution containing 40 per cent, .of 
formaldehyde. If 1 part of formalin is added to 10 parts of water, the 
resultant solution has the disinfecting value of the 5 per cent, carbolic 
acid solution. 

7. Creolin, Tricresol and Lysol. — Cresol has about the same disin- 
fecting value as pure carbolic acid; tricresol and lysol are about three 
times as powerful. 

The proprietary disinfectants, w T hich are so often widely advertised, 
and whose composition is kept secret, are relatively expensive and 
frequently unreliable or inefficient. Their value should be stated in 
comparison with carbolic acid, so that their strength may be known. 
It should be remembered that substances which destroy or disguise 
bad smells are not necessarily disinfectants, and that there are very 
few disinfectants that are not poisonous when taken internally. 

The diseases to be commonly guarded against, outside of surgery, by 
disinfection are scarlet fever, measles, diphtheria, tuberculosis, small- 
pox, typhoid fever, bubonic plague, and cholera. 

Disinfection of Hands and Person. — Dilute the 5 per cent, carbolic 
acid solution with an equal amount of water or use the 1 to 1000 
bichloride solution without dilution. Hands soiled in caring for 
persons suffering from contagious diseases, or soiled portions of the 
patient's body, should be immediately and thoroughly soaked with 
one of these solutions and then w r ashed with soap and water, and 
finally immersed again in the solutions. The nails should always 
be kept short and clean. Before eating, the hands should be first 
washed in one of the above solutions, and then thoroughly scrubbed 
with soap and water by means of a brush. 



PRACTICAL DISINFECTION AND STERILIZATION 189 

Soiled Clothing, Towels, Napkins, Bedding, etc., should, on removal, be 
immediately immersed in the 2.5 per cent, carbolic acid solution, in 
the sick room, and soaked for one or more hours. Articles such as beds, 
woolen clothing, etc., which cannot be washed, should be thoroughly 
exposed to formaldehyde gas. This is not necessary after measles. 

3. Food and Drink. — Food thoroughly cooked and drinks that have 
been boiled are free from disease germs. Foods and drinks, after cook- 
ing or boiling, if not immediately used, should be placed when cool in 
clean dishes or vessels and covered. In the presence of an epidemic 
of cholera or typhoid fever, milk and water used for drinking, cooking, 
washing dishes, etc., should be boiled before using, and all persons 
should avoid eating uncooked food and fresh vegetables. 

4. Discharges of all Kinds from the Mouth, Nose, Bladder, and Bowels 
of patients suffering from contagious diseases should be received into 
glass, metal or earthen vessels containing the carbolic acid solution, 
or milk of lime, or they should be removed on pieces of cloth, which 
are immediately immersed in one of these solutions or boiled or 
destroyed by fire. Special care should be observed to disinfect at 
once the vomited matter and the intestinal discharges from cholera 
patients. In typhoid fever the urine and the intestinal discharges, 
and in diphtheria, measles, and scarlet fever the discharges from the 
throat and nose all carry infection and should be treated in the same 
manner. The volume of the solution used to disinfect discharges 
should be at least twice as great as that of the discharge, and should 
completely mix with it and cover it. The strength of the disinfectant 
solution is reduced according to its dilution in the final mixture. 
After standing for an hour or more the discharges, with the exception 
of the feces, may be thrown into the water-closet. 

Masses of feces are extremely difficult to disinfect except on the sur- 
face, for it takes disinfectants such as the carbolic acid solution some 
twelve hours to penetrate to their interior. If fecal masses are to be 
thrown into places where the disinfectant solution covering them will 
be washed off, it will be necessary to be certain that the disinfectant 
has previously penetrated to all portions and destroyed the disease 
germs. This can be brought about by stirring them with the disin- 
fectant and allowing the mixture to stand for one hour, or by washing 
them into a pot holding soda solution which is already at the boiling 
temperature, or later will be brought to boiling. 

5. Sputum from Consumptives.— The importance of the proper dis- 
infection of the sputum is still underestimated. Consumption is an 
infectious disease, and is always the result of transmission from the 
sick to the healthy or from animals to man. The sputum contains 
the germs which cause the disease, and in a large proportion of cases 
is the source of infection which is especially dangerous in early child- 
hood. In all cases, therefore, the sputum should be disinfected when 
discharged. It should be received in covered cups containing the 
carbolic acid or milk of lime solution. Handkerchiefs soiled by sputum 
should be soaked in the carbolic acid solution and then boiled, Dust 



190 PRACTICAL USE OF DISINFECTANTS 

from the walls, mouldings, pictures, etc., in rooms that have been 
occupied by consumptive patients, where the rules of cleanliness have 
not been carried out, contain the germs and will produce tuberculosis 
in animals when used for their inoculation; therefore, rooms should 
be thoroughly renovated or disinfected before they are occupied by others. 

6. Closets, Kitchen and Hallway Sinks, etc. — The closet should never 
be used for disinfected discharges until they have been thoroughly 
disinfected; when done as an additional safeguard, one quart of car- 
bolic acid solution or 5 per cent, solution of formalin should be poured 
into the pan (after it is emptied) and allowed to remain there. Sinks 
should be flushed at least once daily. 

7. Dishes, Knives, Forks, Spoons, etc., used by a patient should, as a 
rule, be kept for his exclusive use and not removed from the room. 
This will prevent accidents. They should be washed first in the 
carbolic acid solution, then in boiling hot soapsuds, and finally rinsed 
in hot water. The remains of the patient's meals may be burned 
or thrown into a vessel containing the carbolic acid solution of milk 
of lime, and allowed to stand for one hour before being thrown away. 

S. Rooms and Their Contents. — Rooms which have been occupied 
by persons suffering from contagious disease should not be again 
occupied until they have been thoroughly cleaned. If this is done 
thoroughly disinfection is not necessary, since it is true that when 
the patient is freed from isolation probably the great majority of 
disease germs have already died. If any remain in places where 
they might cause infection they will almost certainly be removed while 
the rooms are being cleaned. It may be advisable to do it, however, 
so as to give a feeling of security to those who are to occupy the rooms. 
The danger from infection is much greater when cases are removed 
during the acute illness. For disinfecting rooms careful fumigation 
with formaldehyde gas should be employed unless vermin are to be 
killed, when sulphur fumes should be substituted. Carpets, curtains 
and upholstered furniture which have been soiled by discharges, or 
which have been exposed to infection in the room during the illness, 
may be removed for disinfection to chambers w T here they can be 
exposed to formaldehyde gas and moderate warmth for twelve to 
twenty-four hours, or to steam. Some carpets, such as many Wiltons, 
are discolored by moist steam, while formaldehyde fumigation gives 
only surface disinfection it is sufficiently effective, since any germs 
which penetrated the carpets or furniture so deeply as to be unaffected 
are so held as to be harmless. Wood-work, floors and plain furniture 
must be thoroughly washed with the soapsuds and bichloride solu- 
tion. After the disinfection is finished it is w T ell to remove the dried 
bichloride of mercury from the walls and wood-work. 

9. Rags and Other Articles of Little Value, which have been soiled 
by discharges or infected in other ways, should be boiled or burned. 

If). In case of death the body should be completely wTapped in several 
thicknesses of cloth wrung out of the carbolic or bichloride solution, 
and when possible placed in a hermetically sealed coffin. 



PRACTICAL DISINFECTION AND STERILIZATION 191 

Methods of Cleanliness and Disinfection to be Used in Homes and 
Public Places. — 1. Water-closet Bowls and all Receptacles for Human 
Excrement should be kept perfectly clean by frequent flushing with a 
large quantity of water, and as often as necessary disinfected with crude 
carbolic acid or other efficient solution. The wood-work around and 
beneath them should be frequently scrubbed with the hot soapsuds 
solution. 

2. Cesspool and Privy Vaults. — An abundance of milk of lime or 
chlorinated lime should be thrown into these daily, and their contents 
should be frequently removed. 

3. The Woodwork in School Houses. — Floors, door-handles and all 
woodwoik touched by the scholars' hands should be scrubbed daily 
with hot soapsuds. 

4. Spittoons in all Public Places should be emptied daily and washed 
with the hot soapsuds solution, after which a small quantity of the 
carbolic acid solution or milk of lime should be put in the vessel to 
receive the expectoration. 

5. Cars, Ferry-boats and Public Conveyances. — The floors, door- 
handles, railings, and all parts touched by the hands of passengers 
should be washed frequently with the hot soapsuds solution. Slat- 
mats from cars, etc., should be cleaned by scrubbing with a stiff brush 
in the hot soapsuds solution. 

The Practical Employment of Formaldehyde Gas in the Surface 
Disinfection of Rooms and the Disinfection of Goods which would be 
Injured by Heat. — Formaldehyde gas has come into such general use 
and is for many purposes so valuable, that a somewhat detailed 
description may be given of the methods employed to generate and 
use it. 

The destructive action -of formaldehyde gas in microorganisms 
depends upon a number of factors, in its practical application for 
purposes of disinfection. The chief of these are its concentration in 
the surrounding atmosphere, the length of the contact, the existing 
temperature, the accompanying moisture, and the nature of the 
organism. It is not an efficient insecticide as sulphur dioxide is, but 
has the great advantage of not injuring the materials to be disinfected. 

Concentration. — The necessary concentration of gas in the surround- 
ing atmosphere varies with each species of microorganisms which are 
to be killed, as some of these resist chemical agents much more than 
others, and also with the freedom of access of the gas to the bacteria, 
for if they are under cover or within fabrics a greater amount of gas 
must be generated than if they are freely exposed. 

For purely surface disinfection, when the common pathogenic bacteria 
are to be destroyed, there will be required, according to the method 
used, ten to twelve ounces of formalin of full strength, or its equivalent 
to 1000 cubic feet of air space. 

If the gas is to pass through heavy goods the concentration must 
be doubled and moderate heat added (45° C. or above), as the gas 
penetrates through fabrics with difficulty. 



192 PRACTICAL USE OF DISINFECTANTS 

Although formaldehyde gas does destroy bacteria with the amount 
of moisture usually present in the air, it acts much more powerfully 
and certainly when additional moisture is present, and best when it 
is present up to the point of saturation. 

Temperature. — Every additional degree of temperature increases not 
only the activity of formaldehyde gas, but also its penetrating power. 
For heavy goods it is essential to have a moderately high heat, but 
one still below that which would injure fabrics. The production of a 
partial vacuum in the chambers before the introduction of the gas still 
further assists its penetration. 

Length of Exposure. — This depends upon the nature of the disease 
for which the disinfection is carried out, also upon the penetration 
required, the concentration of the gas used, the amount of moisture in 
in the air, temperature of the air, and the size and shape of the room. 
For surface disinfection in rooms, when as much as twelve ounces of 
formalin are used for each 1000 cubic feet, five hours' exposure is 
amply sufficient, most bacteria being killed within the first thirty 
minutes. For the destruction of microorganisms protected by even 
a layer of thin covering, double the amount of formalin and double 
the time of exposure should be allowed, and even then the destruction 
of many species of non-sporebearing bacteria, in ordinary rooms, 
cannot be depended upon. When complete disinfection is demanded, 
and deep penetration of gas is required, the goods must be placed in 
chambers where moderate heat can be added and all leakage of gas 
prevented. 

In order to insure complete sterilization of the articles they should 
be so placed as to allow of a free circulation of the gas around them — 
that is, in the case of bedding, clothing, etc., these should either be 
spread out on perforated wire shelves or loosely suspended in the 
chamber. The aid of a partial vacuum facilitates the operation. Up- 
holstered furniture and articles requiring much space should be placed 
in a large chamber, or, better, in a room which can be heated to the 
required temperature. 

The most delicate fabrics, furs, leather, and other articles, which 
are injured by steam, hot air at 230° F., or other disinfectants, are 
unaffected by formaldehyde in either texture or color. 

The vapors of formaldehyde are extremely irritating to the mucous 
membrane of the eyes, nose and mouth, causing profuse lacrimation, 
coryza, and flow of saliva; but so far as known formaldehyde gas is 
comparatively non-toxic to the higher forms of animal life. Never- 
theless, a certain degree of caution should be observed in the use of 
this agent. It is practically inert as- an insecticide except in extremely 
great concentrations; such insects as roaches, flies, and bedbugs, are 
not, as a rule, affected. 

Disinfection of Books. — Books may be satisfactorily disinfected by 
means of formaldehyde gas in a special room, or in the ordinary steam 
chambers, as above described, and under the same conditions of 
volume of gas, temperature and time of exposure. The books should 



PRACTICAL DISINFECTION AND STERILIZATION 193 

be arranged to stand as widely open as possible upon perforated wire 
shelves, set about one or one and a half feet apart in the chamber. A 
chamber having a capacity of 200 to 250 cubic feet would thus afford 
accommodation for about one hundred books at a time. 

Books, with the exception of their surfaces, cannot be satisfactorily 
disinfected by formaldehyde gas in the book cases of houses or libraries, 
or anywhere except in special chambers constructed for the purpose, 
because the conditions required for their thorough disinfection cannot 
otherwise be complied with. It is hardly conceivable that such 
books could have been infected. 

The bindings, illustrations, and print of books are in no way affected 
by the action of formaldehyde gas. 

Disinfection of Carriages, etc. — Carriages, ambulances, cars, etc., can 
easily be disinfected by having built a small, tight building in which 
they can be enclosed and surrounded with formaldehyde gas. Such 
a building is used for disinfecting ambulances in New York City. 
With the apparatus thus employed a large amount of formalin is 
rapidly vaporized and superficial disinfection is completed in sixty 
minutes. 

Methods of Providing Formaldehyde Gas. — Formaldehyde, or 
formic aldehyde, was originally obtained by von Hoffmann (1867) 
by passing the vapor of methyl alcohol (wood alcohol) mixed with 
air over finely divided platinum heated to redness. Formaldehyde is a 
gaseous compound with an extremely irritating odor. At a tempera- 
ture of 68° F. the gas is polymerized — that is to say, a second body is 
formed, composed of a union of two molecules of formaldehyde. This 
is known as "paraformaldehyde," and is a white soapy body, soluble 
in boiling water and in alcohol. Formaldehyde is sold in commerce as 
a clear, watery liquid containg from 33 to 40 per cent, of the gas and 
10 to 20 per cent, of methyl-alcohol, its chief impurity. This solution 
is known as "formalin." If formalin is evaporated or concentrated 
above .40 per cent., paraformaldehyde results; and when this is dried 
in vacuo over sulphuric acid a third body, " trioxymethylene," is pro- 
duced, consisting of three molecules of formaldehyde. This is a white 
powder. The solid polymers of formaldehyde, when heated, are 
again reduced to the gaseous condition; ignited, they finally take 
fire and burn with a blue flame. When burned they have no germi- 
cidal properties. 

Various forms of apparatus can be properly employed to liberate 
formaldehyde gas for purposes of disinfection. There are two essentials 
to any good method, namely, that the formaldehyde gas is given off 
quickly, and that there is no great loss by deterioration of the formalin. 

Wood Alcohol. — A number of lamps have been devised, all very 
much on the principle originally proposed, which bring about the 
incomplete oxidation of methyl alcohol by passing the vapors mixed 
with air over incandescent metal. Although disinfection can be carried 
out by the best of these lamps, none of them up to the present time 
have proved to be satisfactory. 
13 



194 PRACTICAL USE OF DISINFECTANTS 

Trioxy methylene or Paraform. — This system consists in heating the 
solid polymer of formaldehyde, of which there are several methods. 
They arc somewhat expensive but efficient and are very generally 
used. The formaldehyde must be protected fiom burning to retain 
its germicidal properties. A number of outfits are made which 
consist of a receptacle holding the paraform and another for producing 
the heat. It is well to use about twice the amount advised by the 
manufacturer in order to be certain of the result. 

Formalin. — The commercial solution known as formalin, containing 
about 40 per cent, of formaldehyde gas, is also commonly employed 
in the various methods of generating the gas for disinfecting purposes. 
It is not always up to standard, and, being volatile, there is a certain 
loss if not well kept. In winter there is a decided deterioration, owing 
to the polymerization of trioxymethylene. For these reasons it is well 
to use an excess of the liquid in practical work if the exact strength of 
the formalin has not recently been determined. There are several 
methods in common use for liberating formaldehyde gas from formalin, 
a few of which may be mentioned. 

1. Formalin by Boiling and Passing the Vapor through a Super- 
heated Coil or Chamber. — This system consists in heating the ordinary 
formalin to a high temperature in an incandescent copper coil or 
chamber, and allowing the vapors to pass off freely. It is claimed 
for this method that the degree of heat necessary to break up the 
polymerized products formed is supplied, and then a loss of formalde- 
hyde is prevented. A further action of the intense heat in the copper 
tube on the solution is partially to convert the methyl alcohol contained 
in commercial formalin into formaldehyde gas by oxidation, thereby 
utilizing a part of the methyl alcohol and increasing the amount of 
formaldehyde. 

2 Formalin on Sheets. — A very simple method is to pour on folded 
sheets 16 ounces of formalin per 1000 cubic feet and then stretch 
them out over lines in a room and leave for ten hours. If the room 
is tightly sealed very fair surface disinfection will take place. 

3. Lime and Permanganate of Potash with Formalin. — Satisfactory 
results in disinfection have been obtained from the following com- 
bination of chemicals: 2 ounces of a quick-slaking, coarsely granular 
lime (calcium oxide); 5 ounces of permanganate of potash; \ gram 
oxalic acid; 5 ounces formalin (40 per cent, strength); 2\ ounces of 
water. This is sufficient in quantity to disinfect 1000 cubic feet of 
space in five hours. It is used as follows: The lime and permanganate 
of potash are mixed together in a pan at least 10J inches in diameter 
and 3| to 4 inches in depth Over this is poured the freshly prepared 
mixture of formalin, oxalic acid and water A rapid evolution of gas 
takes place. 

Another combination is: lime, 2.7 ounces; potassium permanganate 
5.5 ounces; formalin, 7.4 ounces; water, 2.7 ounces. The technic is 
as follows: The lime and permanganate are mixed in a wide, deep 
pan as above, and the freshly prepared formalin and water mixture 
is poured over it, 



PRACTICAL DISINFECTION AND STERILIZATION 195 

4. Lime and Formalin Method. — To 10 ounces of 40 per cent, formalin 
slowly add 1 ounce of concentrated sulphuric acid; pour this solution 
on to 2 pounds of quicklime that has previously been broken into 
small lumps and placed in a dairy pan not less than 12 inches in diam- 
eter. The liberation of a large amount of gas in a short time more than 
compensates for the loss by polymerization, and disinfection is effected 
by a quick union of the gas and the microorganisms to be destroyed. 
Saturated solution of aluminum sulphate may be used instead of 
concentrated sulphuric acid. 

Wilson's Formaldehyde Generator for Large Chambers. — This gene- 
rator is made of ordinary iron steam pipe and can be manufactured 
in any pipe-cutting establishment in a few hours. It consists of an 
outer steam jacket of 6-inch pipe, 2 feet long, and capped at 
both ends. Through the upper cap there is a 4-inch opening, with 
a thread, through which projects an inner chamber for formalin. 
This chamber consists of a 4-inch pipe, 22 inches long, capped at the 
upper end and welded or capped at the lower end. The upper end of 
this pipe is so threaded as to permit of its being screwed through the cap 
of the outer or steam jacket before that cap is screwed on. The cap 
of the formalin chamber is fitted on the same thread that passes through 
the cap of the steam jacket. The intake for steam is near the top of 
the steam jacket, through a J-inch pipe, and the steam is controlled 
by a globe valve. The outlet for steam or drip is through a |-inch 
pipe from the bottom cap of the chamber and is controlled by a globe 
valve. The intake for formalin is through the upper cap of the formalin 
chamber by means of a J-inch pipe controlled by a globe valve. The 
outlet for formalin is a |-inch pipe through the upper cap of the for- 
malin chamber. 

Controls must be made to test the efficiency of room disinfection by 
any of the methods above described if it is necessary to know that 
all disease germs have been killed. 

Sulphur Dioxide in House Disinfection. — Sulphur dioxide gas has 
been extensively used for the disinfection of hospitals, ships, houses, 
clothing, etc. This gas is a much more active germicide in a moist 
than in a dry condition — due, no doubt, to the formation of the more 
powerful disinfecting agent, sulphurous acid (H 2 S0 3 ). In a pure 
state anhydrous sulphur dioxide (S0 2 ) does not destroy spores, 
and is not certain to destroy bacteria in the vegetative form. As the 
result of a large number of experiments with S0 2 , however, as a dis- 
infectant it has been determined that an exposure for eight hours to 
an atmosphere containing at least 4 volumes per cent, of this gas in 
the presence of the moisture usually present in the air will destroy 
most, if not all, of non-sporebearing pathogenic bacteria. 

Four pounds of sulphur should be burned for every 1000 cubic feet; 
this will give an excess of gas. The sulphur should be broken into 
small pieces and put into a pan sufficiently large not to allow the 
melted sulphur to overflow. This pan is placed in a much larger pan 
holding a little water. The cracks of the room should be carefully 



196 PRACTICAL USE OF DISINFECTANTS 

pasted up and the door, after closing, also sealed. Upon the broken 
sulphur is poured 3 to 4 ounces of alcohol and the whole lighted by a 
match. The alcohol is not only for the purpose of aiding the sulphur 
to ignite, but also to add moisture to the air. An exposure of eight to 
twelve hours should be given. 

Sulphur fumigation carried out as above indicated is not as efficient 
as formaldehyde fumigation, but suffice for surface disinfection for 
diphtheria and the exanthemata. 

Advantages of Formaldehyde Gas over Sulphur Dioxide for Disin- 
fection of Dwellings. — Formaldehyde gas is superior to sulphur dioxide 
as a disinfectant for dwellings: (1) Because it is more efficient in its 
action; (2) because it is less injurious in its effects in household goods; 
(3) because when necessary it can be easily supplied from a generator 
placed outside of the room and watched by an attendant, thus avoiding, 
in some cases, danger of fire. 

PUBLIC STEAM DISINFECTING CHAMBERS. 

These are used much less than formerly. There are now few, if 
any, cities in which carpets, bedding and other materials are removed 
from rooms for disinfection after being occupied by persons suffering 
from contagious diseases. 

These chambers should be of sufficient size to receive all necessary 
goods, and may be either cylindrical or rectangular in shape, and are 
provided with steam-tight doors opening at either end, so that the 
goods put in at one door may be removed at the other. When large 
the doors are handled by convenient cranes and drawn tight by drop- 
forged steel eye bolts swinging in and out of slots in the door frames. 
The chambers should be able to withstand a steam pressure of at least 
one-half an atmosphere, and should be constructed with an inside 
jacket, either in the form of an inner and outer shell or of a coil of pipes. 
This jacket is filled with steam during the entire operation, and is so 
used as to bring the goods in the disinfecting chamber up to the neigh- 
borhood of 220° F., before allowing the steam to pass in. This heats the 
goods, so that the steam does not condense in coming in contact with 
them. It is an advantage to displace the air in the chamber before 
throwing in the steam, as hot air has far less germicidal value than 
steam at the same temperature. To do this, a vacuum pump is attached 
to the piping, whereby a vacuum of fifteen inches can be obtained 
in the chamber. The steam should be thrown into the chamber in 
large amount, both above and below the goods, and the excess should 
escape through an opening in the bottom of the chamber, so as more 
readily to carry off with it any air still remaining. The live steam 
in the chamber should be under a pressure of two or three pounds so 
as to increase its action. 

To disinfect the goods, place them in the chamber, close tight the 
doors, and turn the steam into the jacket. After about ten minutes, 
when the goods have become heated, a vacuum of 10 to 15 inches is 



PUBLIC STEAM DISINFECTING CHAMBERS 197 

produced, and then the live steam is thrown in for twenty minutes. 
The steam is now turned off, a vacuum is again formed, and the 
chamber again superheated. The goods are now thoroughly disin- 
fected and dry. In order to test the thoroughness of any disinfection, 
or any new chamber maximum, thermometers are placed, some free 
in the chamber and others surrounded by the heaviest goods. It will 
be found that, even under a pressure of three pounds, live steam will 
require ten minutes to penetrate heavy goods. 

In the practical application of steam for disinfecting purposes it 
must be remembered that while moist steam under pressure is more 
effective than streaming steam, it is scarcely necessary to give it the 
preference, in view of the fact that most known pathogenic bacteria 
produce no spores and the spores of the few that so develop them are 
quickly destroyed by the temperature of boiling water, and also that 
"superheated" steam is less effective than moist steam. When con- 
fined steam in pipes is "superheated" after its generation, it has about 
the same germicidal power as hot, dry air at the same temperature. 

Disinfection of Hands, Instruments, Ligatures and Dressings for Oper- 
ations. — Instruments. — All instruments, except knives, after having been 
thoroughly cleansed, are boiled for three minutes in a 1 per cent, 
solution of washing soda. Knives, after having been thoroughly 
cleansed, are washed in alcohoj or other non-corroding disinfectant 
and wiped with sterile gauze and then put into boiling soda solution 
for one minute. This will not injure their edges to any great extent. 

Gauze. — Gauze is sterilized by moist heat in an Arnold steam 
sterilizer for one hour or in an autoclave for thirty minutes. It is 
placed in a perforated cylinder or wrapped in clean towels before being 
put in the sterilizer, and only opened at the operation. 

Ligatures. — Catgut. — Boil for one hour in alcohol under pressure 
at about 97° C. It is often put in sealed glass tubes, which are boiled 
under pressure. These remain sterile indefinitely. The alcohol does 
not injure the catgut. If desired, the catgut can be washed in ether 
and then soaked a short time in bichloride before heating in alcohol. 
Silver wire, silk, silkworm gut, rubber tubing, and catheters are boiled 
the same as the instruments. Ligatures already sterilized in their 
containers are now supplied by dealers. 

Hand Brushes. — These should be boiled in soda solution for ten 
minutes. 

The Skin of Patients. — It is impossible to sterilize the deeper por- 
tions of the skin, but sufficient surface bacteria can be removed 
to render infection rare. The skin is washed thoroughly with warm 
green soap solution, then with alcohol, and finally with 1 to 1000 
bichloride. A compress wet with a 25 per cent, solution of green soap 
may be placed on, covered with rubber tissue, and left for three to twelve 
hours, and after its removal the skin is washed with ether, alcohol, and 
bichloride solution, and then covered with a gauze compress previously 
moistened with 1 to 1000 bichloride of mercury solution. At the oper- 
ation the skin is again scrubbed with green soap solution followed by 



19S PRACTICAL USE OF DISINFECTANTS 

ether, alcohol, and then with the bichloride of mercury solution. In 
some places the bichloride compress is replaced one hour before the 
operation by a pad wet in 10 per cent, solution of formalin. 

The Hands. — In one method the hands are washed in hot soap and 
water for five minutes, using the nail brush. They are then soaked in 
85 per cent, alcohol for one minute and scrubbed with a sterile brush. 
They are finally soaked in a 1 to 1000 bichloride of mercury solution 
for two minutes. The alcohol and bichloride are sometimes combined 
and used together. Another method is as follows: Skin of operator 
is scrubbed for five minutes with green soap and brush, then washed 
in chlorinated lime and carbonate of soda in proportions to make good 
lather; washed off in sterile water, and then scrubbed with brush in 
warm bichloride of mercury solution 1 to 1000. Owing to" the risk of 
leaving untouched bacteria under the nails and in cracks of the skin, 
sterilized rubber or cotton gloves are now being generally used in 
operations. 

Mucous Membranes. — Here absolute sterilization cannot be achieved 
without serious injury to the tissues. The usual method is to use 
some cleansing solution with moderate germicidal properties so as to 
remove as many bacteria as possible and limit the activities for a 
time of those remaining, while the resistance of the tissues is left 
unimpaired. The following examples give some of the methods 
employed. The mucous membranes of the mouth and throat are 
cleansed by a solution consisting of equal parts of peroxide of 
hydrogen and lime water. In the nostrils it is better to employ 
the milder solutions, such as diluted DobelFs or listerine. These 
are also used in the mouth instead of the peroxide. The vagina is 
swabbed out thoroughly with sterile warm soaps and water, and then 
irrigated with a 2 per cent, carbolic acid or 1 to 1000 bichloride of 
mercury solution. 

Wounds. — It is impossible to disinfect quickly the surfaces of infected 
wounds without doing injury to the tissues involved. 

Various solutions such as neutral hypochlorite solutions advised 
by Dakin gradually clear a wound of infection. 

Hypodermic and Other Syringes. — These when not boiled are sterilized 
by drawing up into them boiling water a number of times and then 
finally a 5 per cent, solution of carbolic acid, this to be washed out by 
boiling water after three minutes. If cold water is used the carbolic 
acid solution should remain in the barrel of the syringe for ten minutes. 
Great care should be taken to wash out all possible organic matter 
before using the carbolic acid or boiling to sterilize. Syringes made 
entirely of glass or of glass and asbestos can be boiled in soda solution. 

THE STERILIZATION OR PASTEURIZATION OF MILK IN THE 

HOME. 

Milk is best sterilized by heat, for nearly all chemicals, such as boric 
acid, salicylic acid, and formalin, are not only slightly deleterious 



STERILIZATION OR PASTEURIZATION OF MILK 199 

themselves but also make the milk less digestible, and therefore less 
fit for food. Formalin is the least objectionable of the three. Milk 
may be sterilized at a high or low temperature — that is, at the boiling 
temperature, or at a lower degree of heat obtained by modifying the 
steaming process. Milk heated as high a temperature as 100° C, is 
not altogether desirable for prolonged use for infants, as the high 
temperature causes certain changes in the milk which make it less 
suitable as food for them. 

Complete sterilization destroys all the germs in milk, and so, if no 
new ones gain entrance, prevents permanently fermentative changes. 
This requires boiling for fifteen to forty-five minutes or two or three 
consecutive days, according to the presence or absence of certain 
spores. 

Pasteurization. — The changes due to boiling are almost altogether 
avoided if a temperature below 70° C. is used. It is recommended, 
therefore, that the lowest temperature be used for partial sterilization 
which will keep the milk wholesome for twenty-four hours in the 
warmest weather and kill the tubercle, typhoid, and other non-spore- 
bearing bacilli. Raising the milk to a temperature of 60° C. for twenty 
minutes, 65° C. for fifteen, 70° C, for five, 75° C. for two, or 80° C. for 
one minute will accomplish this. Exposure for even one minute at 
70° C. destroys 98 per cent, of the bacteria which are not in the spore 
form. Fully 99 per cent, of tubercle bacilli are destroyed. One of the 
many forms of apparatus for pasteurizing milk is the following: 

(a) A tin pail or pot, about 10 inches deep by 9 inches in diameter, 
provided with the ordinary tin cover which has been perforated with 
eight holes each an inch in diameter. 

(b) A wire basket, with eight nursing bottles (as usually sold). 

(c) Rubber corks for bottles and a bristle brush for cleaning them. 

Directions (Koplik). — Place the milk, pure or diluted (as the phy- 
sician may direct) in the nursing bottles and put the latter in the wire 
basket. Pour only sufficient milk for one nursing in each bottle. Do 
not cover the bottles at first. 

Having previously poured about two inches of water in the tin 
pail or pot and brought it to the boiling-point, lower the basket of 
nursing bottles slowly into the pail. Do not allow the bottles to touch 
the water or they will crack. Put on the perforated cover and let the 
steaming continue for ten minutes; then remove the cover and firmly 
cork each bottle. After replacing the cover, allow the steaming to 
continue for fifteen minutes. The steam must be allowed to escape 
freely or the temperature will rise too high. 

The process is now complete. Place the basket of bottles in a cool, 
dark place or in an ice-chest. The bottles must not be opened until 
just before the milk is to be used, and then it may be warmed by 
plunging the bottle in warm water. If properly prepared the milk 
will taste but little like boiled milk. 

The temperature attained under the conditions stated will not exceed 
in extreme cases 87° C. (188° C). 



200 PRACTICAL USE OF DISINFECTANTS 

In another admirable method (Freeman) a pail is filled to a certain 
mark with water, and then placed on the stove until the water boils. 
It is then removed, and immediately a milk-holder, consisting of a 
series of zinc cylinders, is lowered with its milk bottles partially full 
of milk. The cover is again applied. The heat of the outside water 
raises the temperature of the milk in ten minutes to about 65° C. 
(150° F.), and holds it nearly at that point for some time. After twenty 
minutes the milk-holder is removed, placed in cold water and quickly 
cooled. The milk is kept in the ice-chest until used. When milk is 
pasteurized in large quantities it should always be done by the "holding 
process" as the so-called "flask" pasteurization is unreliable. Milk 
should be pasteurized when it is as fresh as possible, and only sufficient 
milk for twenty-four hours should be pasteurized at one time. If after 
nursing the infant leaves some milk in the bottle, this should be thrown 
away. 

Care of the Bottles. — After nursing, the bottles should be filled with 
a strong solution of washing soda, allowed to stand twenty-four hours, 
and then carefully cleaned with a bottle brush. The rubber corks and 
nipples after using should be boiled in strong soda solution for fifteen 
minutes and then rinsed and dried. 

After milk has been heated it should, of course, never be put into 
unsterilized bottles, as this will partially defeat the object of heating. 



I 



CHAPTER V. 

EPIDEMIOLOGY. 

By GEORGE A. SOPER, Ph.D. 

What is Epidemiology? — Epidemiology is the scientific study of 
infections. Infections are the links which connect one case of disease 
with another. 

In its narrowest application epidemiology deals simply with the 
statistical aspects of epidemics. In its broadest sense it includes 
whatever conditions and things cause one case of disease to lead to 
another. In the sense in which it is used here, epidemiology means 
the study of infections from the analytical and practical standpoints 
with the object of determining the essential facts about their causa- 
tion and showing how they may be controlled. This body of knowl- 
edge does not lie clearly within the province of any other branch or 
department of learning. 

Epidemiology is a branch of applied science in that it makes use of 
the facts and principles of other sciences for the accomplishment of 
its ends. Like other departments of applied science, its scope is not 
confined to any particular type, kind or class of objects, reactions or 
functions but it appropriates to its use such results as it needs from 
whatever sources may be available. This free appropriation, together 
with a keen estimation of the data and a particularly rigid application 
of the inductive process of reasoning, are distinguishing marks of 
epidemiological work. 

Epidemiology differs from hygiene in that the one is confined to the 
investigation of disease transmission while the other concerns itself 
with procedures which promote, or tend to promote, health: health 
being regarded not merely as the absence of disease but as a positive 
and variable condition of the body and mind. It differs from what 
has come to be known as the "public health'' in that the latter con- 
cerns itself essentially with broad, administrative functions. Epidemi- 
ology may be contrasted with sanitary science which seeks to promote 
health through the observance of correct principles relating to the 
environment. Epidemiology possesses a more restricted field than 
hygiene or public health or sanitary science; it serves partly as a basis 
for all of these. 

The object of epidemiology is to explain why diseases spread, what 
courses the infections follow, how they can be checked and to what 
extent they are likely to continue under given conditions. To design 
the minuta? of procedures for the prevention of disease is not the sole 
concern of epidemiology. To collect, test, evaluate, classify, assimi- 
late and establish facts and principles from a mass of data is essentially 



202 EPIDEMIOLOGY 

its business. Its highest duty is to establish the laws by which disease 
can be controlled. 

What an Epidemiologist Should Know. — The epidemiologist should 
have a thorough grounding in science. It is desirable, but not neces- 
sary, that he should have a medical education. If he has not a medi- 
cal degree few doctors will believe it possible that he can know anything 
about disease. He will consequently find that his best efforts are often 
undervalued, discredited and rendered futile. The epidemiologist 
should be a specialist and have had a definite course of instruction, 
and much field experience in the line of his specialty. With the 
bearing of the following sciences upon the subject of his work he 
should be sufficiently familiar to enable him to make practical use 
of the resources which they open to him: Pathology, bacteriology, 
parisitology, entomology and zoology, sociology, meteorology, medical 
history, hygiene, logic and graphics. 

He should know the principal diagnostic factors of disease, not 
necessarily with the thoroughness of an expert diagnostician, but 
certainly with sufficiently clear perception to enable him to form a 
shrewd and independent judgment upon obscure cases in their various 
stages of development. With respect to the infectious diseases, he 
should know their periods of infectivity, their periods of incubation, 
the percentage of attacks to be expected from a given number exposed, 
the means of transmission, the means of prevention and the means of 
suppression. 

He should know how to collect and tabulate data and how to ana- 
lyze it. In the interpretations he should be keen to detect similarities 
and differences. He should know how to draw inferences and deduc- 
tions and, where warranted, conclusions. He should be familiar with 
the ways of correlating data ; he should know the theory of probabili- 
ties; how to make and use diagrams and curves both for analytical and 
illustrative purposes. Such things as spot maps and other record 
systems should be among his most familiar resources. 

Methods and Resources. — Since epidemiology seeks to explain the 
occurrence of transmissible diseases it often becomes necessary, in 
order that those explanations may be correct, to test the validity of 
the data which are used and sometimes even to establish them. 

In some respects the tracing of infection is like the tracing of crime, 
for although the one is purposely hidden while the other is not, the 
misconception with which the popular mind regards disease generally 
cause the facts to be lost in a tangle of conflicting evidence. The 
epidemiologist must learn the uncertain value of human testimony 
and be able to penetrate the disguise with which Nature consciously 
or unconsciously seeks to hide the truth. Always he must make notes 
— make notes. The value of his work will often depend entirely upon 
his industry in this direction. 

Nowhere is it more necessary to be able to sift the essential from 
the non-essential, to follow the scent of investigation unerringly 
through a labyrinth of detail, to know how to confine the reasoning 



COMMON OBJECTS AND HIGHER PURPOSES 203 

to what is justified by the data, to know when a proposition is proved 
and not proved, to preserve a sense of proportion, of perspective. 

Of the various kinds of data employed in epidemiological investiga- 
tions, statistics of disease are among the most definite, informing and 
useful. They are seldom, however, as definite and accurate as they 
are supposed to be. The underlying diagnoses are often mistaken, 
the reports incomplete. Yet, in spite of this, vital statistics have 
been called the barometer of public health. Their value depends 
upon their use. To the epidemiologist statistics are the records not 
merely of facts, but of consequences and causes And it is with the 
conditions and causes which have led to diseases, and which may 
result from them, that his mind properly works. 

The statistics and other data with which the epidemiologist deals 
are sometimes collected by others, sometimes by himself. If by others, 
they come to his desk in the form of reports, of prepared tabulations, 
of books of reference. Registrars, health officers, physicians, inspectors, 
bacteriologists, bureaus, boards, commissions may supply the facts. 
Seldom will the epidemiologist have the advantage of well-trained 
assistants unless he produces them himself. He must know how to 
school such help as he can get and how to make use of such abilities 
as are available. 

In some cases the epidemiologist must take the field. He must visit 
hospitals, morgues, laboratories, public institutions, public works, 
dairies, ships, villages, camps. He must interview the sick, rich and 
poor, and learn to talk and to act with tact in such ways as will extract 
the needed data from all of them. 

The epidemiologist's own conception of disease and its cause must 
throughout be kept clear and scientific. Whereas he should look upon 
disease as a reaction which varies within limits with different indi- 
viduals, and with different circumstances, the microbic and other 
causes are specific. The causes may not all be known, but it is the 
business of the epidemiologist to be familiar with such as are estab- 
lished and to try to advance this knowledge as far as possible. 

Common Objects and Higher Purposes. — Bearing in mind that an 
essential function of epidemiology is to investigate the hidden causes 
of disease, we may proceed to consider briefly the ways in which this 
knowledge may be turned to practical account. 

The commonest end to be attained is the stopping of epidemics. 
Supposing scarlet fever, for example, has broken out in a school, it 
becomes necessary to determine how it originated, by what means it is 
being spread and hence in what manner it can be controlled. To make 
the necessary investigations and to propose the remedy is properly 
the work of an epidemiologist. 

Again, typhoid fever continues to be prevalent in a city after large 
sums of money have been spent to improve the water supply and 
other sanitary works. To discover the cause of this unexpected 
condition of affairs requires an investigation which nobody so well 
as a trained epidemiologist can make. 



204 EPIDEMIOLOGY 

Suppose vessels from alleged plague ports are arriving at a well- 
ordered city which has an efficient health department and in which 
the quarantine service is fully alive to its duties. Should the vessel 
be forbidden to discharge her cargo and take on a fresh one for her 
return voyage? If so, what precautions should be taken to insure 
safety? These questions may well be put up to an epidemiologist. 

An unrecognized disease suddenly becomes epidemic in a given 
district; it seems to be contagious, but there is doubt as to its identity 
and uncertainty as to the possibility of its spread. The epidemiologist, 
by noting the way in which the cases occur may trace a relation between 
them which gives the clue to the situation. This is a common case. 
The epidemic behavior of a disease is often the only means of diagnosing 
it. 

The higher w T ork of epidemiology includes the discovery of new 
facts, the classification of existing knowledge and the formulation of a 
body of principles, practices and doctrines for the information and 
guidance of those who wish not only to suppress disease but to prevent 
it. At present much of this material must be ferreted out of works 
of reference to other subjects, particularly bacteriology, where it 
obviously does not belong. It is time that epidemiology was set upon 
its own feet. 

Finally, epidemiology must be taught in medical schools and else- 
where. There is an immense amount of educational work to be done 
in teaching people the simple and well-ascertained things which they 
should know in order that they may not be in danger themselves or a 
needless source of danger to others. The largest field for epidemiol- 
ogists is on health boards. In all branches of epidemiological endeavor 
a promising field lies open for the well-trained and adaptable worker. 

The Function of Prophecy. — It is one of the functions of epidemi- 
ology deliberately to seek to foretell the future. This it does largely 
through the aid of statistical methods. The process appears simple, 
but it is not always easy of application. If a disease has for a long 
time become prevalent at certain intervals of years it is not difficult 
to calculate when it may reasonably be expected again. And the 
behavior of an epidemic of a given disease, like influenza, being well 
known from visitations in the past, it is not hard to forecast the course 
which it will take w 7 hen it again bursts out. Soon after the start 
there is first an increasing rate of increase in the number of new cases 
per day; this is followed by a fairly steady rate of increase; there is 
then a rapidly decreasing rate of increase to the acme, or peak, or 
maximum daily incidence. The disappearance of t}ie epidemic pro- 
ceeds in the reverse order; there is an increasing rate of decrease fol- 
lowed by a fairly uniform decline and the epidemic comes to a con- 
clusion after a period characterized by a decreasing rate of decrease. 
When plotted as a curve, the characteristic epidemic picture is bell- 
shaped. The proportions vary somewhat for different infections. In 
influenza the bell tends to become an inverted V; in typhoid it is 
longer and lower. Knowing the disease, it is sometimes possible to 



THE PRACTITIONERS 205 

anticipate the time of greatest prevalence, the period of decline and 
the end, with considerable accuracy. 

Again, pandemics follow travel routes; and knowing these routes, 
the direction from which to expect the disease is disclosed. For 
example, knowing definitely the channels of infection, as is often 
the case in epidemics due to infected milk, it is possible to foretell 
what persons are in danger of being attacked, where to employ special 
precautions and where to look for fresh cases. 

It is unnecessary to pursue this point. And yet there is one more 
service in the foretelling of events which epidemiology can perform, and 
one which has not received the attention which it deserves. This 
depends upon the observation that epidemics often plainly announce 
their coming beforehand. Thus, before the great typhoid epidemic 
at Ithaca there were lesser epidemics of gastro-intestjnal disease in 
the city each year for many years. Before the 1918 pandemic 
of influenza-pneumonia in America there were minor epidemics of 
influenza; these in turn were preceded by epidemics of more common 
respiratory infections. In view of the great number of instances of 
this kind which could be cited, it is scarcely too much to say that 
great visitations of disease oftentimes throw out danger signals long 
in advance. It is for the epidemiologist to watch for these things, to 
translate their meaning into terms which others can understand and 
to secure suitable action upon them. 

The Practitioners. — The field from which epidemiologists of the 
right measure can be obtained is limited. To most persons the word 
"epidemiology" conveys the impression that there exists in definite 
and serviceable form a body of facts, principles and practices con- 
cerning the spread of transmissible diseases. With this impression 
it is natural to assume that skilled practitioners of this science exist. 
By implication, an epidemiologist is one who is familiar with the 
best methods of investigating the causes of disease and with the 
procedures which it is necessary to take in order to keep infections 
reduced to their lowest terms. It is easy and reasonable to think 
of an epidemiologist as one who follows a definite calling, one to whom 
the hidden causes of infections stand revealed and through whose 
efforts the extension of disease can be checked. 

Unfortunately, epidemiology is an undeveloped science and skilled 
epidemiologists are few. The subject has no collected literature of 
its own, no fixed methods of research. There are few teachers in the 
schools and colleges. There are no legal or scholastic requirements 
for admission to the ranks of its practitioners. At present epidemi- 
ology is not a profession or calling which is followed for itself as is 
medicine, engineering or bacteriology. . It is almost invariably an 
incidental pursuit, taken up vicariously, occasionally and by force 
of circumstances. 

Those who are most competent to do epidemiological work seldom 
speak of themselves as epidemiologists. The practitioners are usually 
physicians, bacteriologists, health officers, .sanitary engineers or 



206 EPIDEMIOLOGY 

statisticians. Any one who professes an interest in epidemic diseases 
may style himself or be styled an epidemiologist, without fear of 
successful contradiction, but there are few whose accomplishments 
warrant their use of the term. 

It is natural to think of epidemiologists as persons who are able to 
stop epidemics as well as investigate them, but this assumption is 
generally unwarranted. In this field, as in others, the ability to 
know does not imply the capacity to do. To know what steps to 
take in order to prevent meningitis, for example, it is necessary to 
know the connections by which the virus passes from person to person, 
but to stop an epidemic of this disease it is necessary to do the things 
which will make those connections impossible. Steps must be taken 
which will so interfere that the virus will fail to reach its mark. To 
initiate steps wmich will prove effective, and not at the same time too 
seriously disturb the vocations and avocations of those among whom 
the work is done, calls for a high order of practical ability. 

It so happens that the investigation of epidemics is a fascinating, 
scientific occupation, while the practical work of handling them' is 
laborious and dangerous. All epidemics are investigated after they 
have broken out, and most of them after they have subsided. On 
the other hand the work of stopping them should be done promptly 
and at the fist sign of danger. Unfortunately this practical work is 
generally undertaken too late. The fire becomes a conflagration 
before the firemen get to work. Most epidemics stop, not because 
any one stops them, but because they exhaust the inflammable material 
or cannot reach it for natural reasons. 

The qualities required to stop an epidemic are those demanded of 
an investigator and more. The epidemic fighter must be a man of 
action as well as of thought. He must not only know what to do, but 
how to do it. It is impossible to place too much emphasis upon this 
capacity to do. People must not alone be told; they must be shown. 
It is useless to talk of isolation and disinfection, of quarantine and 
physical inspection, if ways cannot be found for carrying them out. 
Usually only simple things are needed. It is imperative that every- 
thing be done well. The whole success of anti-epidemic work depends 
upon the excellence with which it is done. The measure of excellence 
lies in the efficacy of the procedures when compared with the incon- 
venience w T hich they entail. 

Epidemic fighting may be regarded as a branch of epidemiological 
work although the term epidemiology, as usually employed, has much 
less relation to practice than to theory. Measures intended for pre- 
ventative purposes, and corrective ones, are not commonly supposed to 
fall within the scope of epidemiological work. 

The Proper Conception of Cause. — It is desirable to define clearly 
what is meant by the w 7 ord cause in epidemiology. There are two 
ways of looking at this matter. We may consider the phenomena of 
infection as it relates to the individual or we may regard the subject 
in the broad aspects of the collective presence of disease. 



THE PROPER CONCEPTION OF CAUSE 207 

When individuals are concerned the search for the cause proceeds 
intensively and along relatively narrow lines. The character of the 
work makes it necessary to enter considerably upon the fields of 
bacteriology and immunology. Studies of this sort usually have par- 
ticular reference to the detection of the immediate and most detailed 
causes. They especially seek to establish facts and principles which 
can be applied in insuring the safety of persons by increasing their 
personal resistance and by showing wherein personal danger lies. 
Thus, the investigation of carriers as sources of typhoid calls for 
intensive work of a very particular character. The biological behavior 
of the infective host assumes a relatively predominating importance. 
The manner in which the virus passes from person to person, although 
a part of this study may not be of so much interest as the behavior 
of the virus in the body. Its capacity to live and retain its virulence 
while making the transit from person to person is a special study. 

Under some circumstances the cause of an infectious disease is 
considered to be simply the virus itself. Thus, the cause of tubercu- 
losis is said to be the bacillus of Koch. This conception of cause may 
be said to be the bacteriologist's view. The epidemiologist's con- 
ception of cause has as much to do with the means of transmission as 
with the germ itself. 

When the phenomena of infection as it affects groups of individuals 
are under consideration, the idea of cause is still broader. The cause 
conceived is more particularly the route or channel by which the virus 
reaches those who become sick. From this point of view the cause 
is not the infecting organism so much as the means by which it is trans- 
mitted. Examples can easily be cited — a sewage-polluted water 
supply is said to be the cause of an outbreak of cholera. Similarly, 
louse-infestation may be said to be the cause of typhus. 

There seem to be three separate and distinct points of view here, but 
in truth the three are but parts of a single large problem. To really 
understand how disease spreads it is necessary to know the focus, the 
virus, the routes by which the virus passes from person to person and 
how it behaves after it reaches its host. And it is in proportion to the 
completeness and exactness of this information that the epidemiologist's 
knowledge is trustworthy and useful. 

It is often difficult, in particular instances, to discover exactly the 
way in which the virus from one person has been able to reach others, 
but it is generally easy enough to make a serviceable guess at it. The 
surmise is based largely on general principles. The guess is likely to 
approximate the truth in proportion to (a) the definiteness with which 
the general principles which apply have been worked out for the par- 
ticular disease in question and (b) the completeness with which the 
observed facts agree with those principles. The principles have been 
well established for some diseases and hardly at all for others. For 
typhoid, for example, they appear to be completely fixed. Conse- 
quently, it is often practicable to show every step which is responsible 
for a typhoid outbreak with the finality of a demonstration. 



2Q8 EPIDEMIOLOGY 

To illustrate, the stools from a typhoid patient are thrown, without 
disinfection, into a water closet whose sewage is later found to leak from 
a broken underground pipe into a well. People who drink from this 
well become sick with typhoid; none who do not use this water are 
attacked. No better proof is needed to show completely the cause 
of this epidemic. Every step in the progress of the germs from their 
focus in the intestines of the sick to the intestines of their victims is 
thoroughly demonstrated. Such complete proof is the ideal toward 
which every epidemiological investigation should aspire. 

What has been said here has had reference to the specific causes of 
epidemic diseases and of epidemics. An effort has been made to make 
the remarks as brief as possible, but it is hoped that enough has been 
said to make it clear that our conception of cause should be as definite 
as possible. The cause of an epidemic is not simply the virus, or the 
means of transmission, or the susceptibility of those persons who are 
attacked, but all these factors taken together. The outbreaks could 
not occur if any of them were missing. 

Types of Outbreaks. — It is sometimes convenient to speak of an 
infectious disease according to the extent or manner of its occurrence. 
It may be endemic, epidemic or pandemic — or sporadic. There is no 
exact definition of any of these terms, but there is a general agreement 
as to their meaning which it is well to bear in mind. 

A disease is endemic when it is more or less securely rooted in a 
region. It may or may not be prevalent. Usually only a few cases 
occur from time to time. Often its presence is scarcely noticed except 
at periods when it breaks out with more or less violence. If the disease 
does not occur as an epidemic or otherwise possess sensational features, 
it may continue to exist unnoticed indefinitely. Cases which occur 
occasionally here and there are sporadic. 

When a disease is endemic its type is often notably mild. Not 
infrequently the name is unknown locally. Its presence, if not taken 
as a matter of course, is commonly regarded as inevitable. From the 
epidemiological standpoint endemic disease is smouldering disease. 
The cases are embers kindled from past fires and ready to break out 
again on suitable occasion. 

Endemic infections are of the utmost interest epidemiologically. 
From time to time most diseases which are ordinarily endemic assume 
larger proportions. They gain in severity. They spread into epi- 
demic form. Something fans the smouldering sparks. What it is 
that does this is one of the mysteries of epidemiology. In investigating 
the history of an epidemic it is always desirable to consider the endemic 
history of the locality. 

Disease is properly called endemic, when, in spite of such precau- 
tions as are taken to prevent it, individual cases and sometimes local 
outbreaks take place. All the great pestilential diseases are endemic 
in certain parts of the world. Typhus is normally endemic in the Near 
East, plague and cholera in certain parts- of China and India, yellow 
fever in Central America, South America and the west coast of Africa. 



TYPES OF OUTBREAKS 209 

Typhoid, which is a genuine pestilential disease and the last great 
filth infection to be banished from civilized communities is endemic 
throughout the western world. Smallpox, scarcely dreaded now where 
vaccination is practised, is nevertheless, widely endemic nearly every- 
where. 

It is reasonable to suppose that if the endemic foci could be dis- 
covered and extinguished, epidemics would no longer be possible. 
Work toward this end is a common procedure. Its object is usually 
to protect particular cities and towns. Improved water supplies and 
drainage systems have this object in view. Sometimes the area to be 
protected is much larger. Efforts are now being made to exterminate 
yellow fever utterly. Economically considered, endemic infections 
are of the utmost importance. 

The spread of pestilence is often slow and insidious at first. In its 
last great visitation, cholera was prevalent in India for fourteen years 
and had obtained a footing in Europe for two years before it made its 
appearance in England. Thereafter it was a constant menace to the 
British Isles for thirty-five years. Before it disappeared it had swept 
away many thousand lives. 

It often happens that several diseases of a given type go hand in 
hand. This fact helps to obscure the situation. Epidemics of diar- 
rhea have sometimes preceded and followed epidemics of cholera. 
During the pandemic of influenza in 1918, other respiratory diseases 
were prevalent. 

Disease may spread to considerable proportions before its preva- 
lence is recognized. Often the first sign of trouble is an excessive 
fatality in some public institution such as an orphan asylum, jail or 
workhouse. A sensational outbreak then occurs. While only occa- 
sional cases were being reported the infection was gaining a firm 
foothold. 

The opposite of an endemic disease with its continual small preva- 
lence is a sudden outbreak. 

A disease is said to be epidemic when it' is generally prevalent. It 
is pandemic when it almost universally prevails over a large territory. 
The area over which the prevalence occurs, the rate at which it spreads, 
its intensity (that is, the proportion of persons attacked to the number 
of those exposed), the duration at any place, the tendency to establish 
new foci, the degree to which the disease attaches itself permanently to 
a locality, and the rate at which it travels from one point to another 
are matters of considerable interest to the epidemiologist. 

A sporadic outburst is one in which scattered cases occur in point of 
time and place where the disease has not been endemic. 

With the conception of an epidemic always comes an idea of a 
definite place or group of people wherein the disease occurs. It is not 
the total number of cases so much as the number in some particular 
locality that is of consequence. Thus, there is a natural inclination to 
attach significance to the place or the immediate circumstances sur- 
rounding the outbreak. 
14 



210 EPIDEMIOLOGY 

Epidemics are often composite phenomena and in order to understand 
them it is sometimes desirable to try to separate them into their com- 
ponent parts. A city epidemic may be made up of neighborhood epi- 
demics and a neighborhood epidemic of household epidemics. 

How the separation can be made will depend upon the disease and 
the type and location of its centers. In outbreaks of cholera in which 
the original focus is the general water supply, the disease is sometimes 
kept going a long time through the establishment of secondary foci, 
such as milk supplies, which become involved after the first wave of 
infectious material has passed by. In most diseases each case should 
be regarded as a potential focus which may lead to other cases in the 
vicinity. 

The Nature of Proof. — We are now prepared to consider the four 
criteria which must be satisfied in order that a case, or a group of 
cases, of infectious disease may be perfectly connected with their 
source : 

1 . There must exist a human source of the infective virus. Strictly 
speaking it is not sufficient in explaining how a man contracted malaria 
to say that he lived where there were mosquitoes, nor, in fact, even to 
say that the mosquitoes were of the anopheles variety. The mosquitoes 
in this case merely represent the means of transmission. We must 
look for some person or persons who possessed the malarial organisms 
in the blood. It is often impossible to find the person who was the 
original source of the virus and in this case it is enough to show that 
there were a number of infected persons to whom the mosquitoes 
could have had access and so secured the virus which they later 
inoculated into the persons who became sick. 

2. Means must exist whereby the virus can pass from its source to 
the individuals who are attacked. The necessity for this second link 
in the chain of proof is generally recognized; it is often, in fact, the 
only one of the four criteria to which much attention is paid. The 
existence of the first is often assumed. Thus, if an epidemic of typhoid 
apparently results from the drinking of a certain spring water, it is 
seldom thought necessary to find out how the spring came to receive 
its infectious material. It is necessary, of course, if the whole cause 
is to be worked out. 

3. The existence of the source and means of transfer must agree in 
point of time with the date of infection. The time factor is of some 
consequence, since the virus of most infectious diseases is rapidly 
destroyed outside of the human body and is seldom known to cling 
about any place or thing for a considerable interval of time. Under 
some circumstances it is true that there seems to be a prolonged 
interval between the escape of the virus from its human source and 
the cases of sickness to which it leads, but it is doubtful whether such 
extraordinarily long periods exist as are commonly supposed. It is 
desirable for the epidemiologist to look for relatively short and direct 
means of transfer. 

4. The nature of the proof which connects an outbreak with its 



THE TWO MAIN ELEMENTS OF INFECTION 211 

cause must be such that a preponderance of facts is in agreement with 
the. conditions which theory shows are necessary and no single fact is 
in opposition to it. We are here considering the question of logic and 
of that branch of logic which has to do with inductive reasoning. 

The method of inductive reasoning which is so much employed in 
epidemiology is full of peril to the unwary, but rightly used and with 
a sufficiency of material to work on, it is capable of the most useful 
results. In epidemiological investigations, deductive as well as induc- 
tive logic is frequently employed. The inductive process is necessary 
in order to establish the grounds for the formulation of a theory. 
The theory formed, the deductive process begins and the consequences 
which follow are reasoned out. 

It remains to point out that a number of predisposing and aggravat- 
ing conditions may contribute materially to cause infection and that the 
epidemiologist must be constantly on his guard against placing too 
much importance upon them. Frequently it is the circumstances 
which favor the spread of disease, instead of the conditions which 
actually produce it, which satisfy the too hasty investigator. 

It is only necessary to name some of the conditions which favor the 
spread in order that their harmful influence may be appreciated. The 
entire category may be mentioned in a general way together, as follows : 
Filth, disorder, poverty, ignorance, neglect, carelessness and indiffer- 
ence. None of these can be said actually to cause disease but they 
certainly favor it. Where they occur disease is likely soon to follow. 

The Two Main Elements of Infection. — Among the many elements 
to be taken into consideration in the study of epidemiological ques- 
tions, there are two of paramount importance: the behavior of the 
infective virus after it reaches its host and the action of the body 
which is attacked. It is the contest between these two great forces 
which constitutes the phenomena of disease. 

Both of these forces vary widely. The virulence of the infective 
agent is not always the same by any means. One kind of virus differs 
from another in virulence and there is much variety in the virulence 
of the same virus under different circumstances. 

Two main classes of infective poisons may be considered, those in 
which the virus increases in the body and has its sole existence there, 
and those which can live for a considerable time outside the body, as 
in water or milk, or some other inanimate substance. 

A virus is not necessarily harmful to the host which it inhabits. It 
may carry on a saprophytic existence without producing any visibly 
ill effects. Carriers of typhoid, diphtheria, meningitis and other 
diseases afford examples of this kind. On the part of the host, sus- 
ceptibility to infection varies not only with respect to the virus of 
different diseases but in many other respects. 

Sometimes the variables which affect virulence and susceptibility 
work together so that infection takes place so spontaneously as to 
possess all the clear and connectible features of proof. Sometimes 
they take opposite directions, in which event there is complexity, 



212 EPIDEMIOLOGY 

delay and either an unusual form of infection or none at all. It is 
probable that a typical case of an infectious disease is contracted 
only under those exceptional conditions wherein the circumstances all 
work favorably toward the one end. 

With relation to the virus, the following deserve to be taken care- 
fully into account: The kind of infective agent, its type, means of 
transmission, amount present, nearness to the susceptible material 
and the repetition of the attack of the virus. 

With relation to susceptibility there are two sets of factors which 
deserve consideration : Those which contribute to infection indirectly 
as extreme fatigue, hunger, cold and mental stress, and those which 
react directly as immunity, natural or acquired, partial or complete. 

These last may result from inherited qualities, from a previous 
attack of the disease, from an immunizing process purposely employed, 
or from physiological conditions most of which axe not yet understood. 
Their duration varies. In some diseases immunity is first acquired 
by an attack and then lost after a more or less prolonged interval of 
time. Persons who are apparently not susceptible to relatively small 
doses of infective virus may succumb to large doses. On the other 
hand, immunity may be accidentally acquired by continued exposure 
to small doses of virus, so that eventually, relatively large doses may 
not produce an attack of sickness in a person who would otherwise 
be susceptible. As an example, it is due perhaps to this relative 
immunization, accidentally brought about by repeated small doses, 
that city people are less susceptible to the respiratory diseases than 
are people fresh from the country. Further, the extreme susceptibility 
of the eskimos and of savage tribes to measles and smallpox, has been 
ascribed to the fact that these aboriginals were not accustomed to 
the infective powers of these diseases. Not only is disease more likely 
to be contracted by people who have never been exposed to it before, 
but the severity of the attack is likely to be greater among those 
who have lived in a region where the disease in question is rare or 
unknown, or in other words, the more common the disease, the more 
mild the attack. Smallpox, for example, is a well nigh universal, but 
a relatively mild disease in Mexico. 

Among the indirect factors which affect the risk of infection are 
weather and climate. These two elements may produce a direct 
effect, as when they alter the amount and character of the excretions, 
or they may give rise to indirect effects as when they lead to crowding 
and to indoor life in general. Again the indirect effect of climate and 
weather has to do with clothing, especially with reference to its ade- 
quacy in protecting the body against cold. Food, especially with 
reference to its quality, quantity and composition is believed to play 
an important part in influencing the immunity which persons may 
exhibit toward infection. Fatigue is generally supposed to favor 
infection, especially when the fatigue is excessive and continual. 
Hygiene, especially with respect to body cleanness, has an obvious 
relation to the possibility of infection. 



RELATION BETWEEN VIRULENCE AND SUSCEPTIBILITY 213 

It is proper to say that there is a school which holds that immunity 
is a very specific and definite condition and that so-called predisposing 
and aggravating factors play but little part in it. According to this 
theory such elements as hunger, cold, fatigue and the stress and 
strains of ordinary life produce little consequence. What seem to be 
variations in susceptibility are really irregularities in the behavior 
of the virus or in its ability to find a suitable point of attack. The 
advocates of this belief are inclined to insist upon experimental data 
to support whatever claims are made in the science of infection. 

It must be admitted fully that the subject of infection cannot 
be set forth with the definiteness of a geometrical diagram. There is 
much about disease which is speculative and inexact. The science of 
immunology is in its infancy. Until there is an abundance of thor- 
oughly established facts and principles, to substitute for the appar- 
ently justifiable beliefs which practical epidemiological research has 
adduced, it would seem that a wise course would be to give some 
weight to the probabilities. 

It is not always possible to say, therefore, exactly in what way and 
to what extent the various factors which make for, or tend to protect 
against disease, are able to operate in addition to the virus, but that 
they may have a powerful if subtle effect, is the opinion of a large 
majority of epidemiologists. 

The Relation between Virulence and Susceptibility. — A number of 
conditions are necessary in order that a virus may make a successful 
attack: (1) The virus must possess a sufficient degree of virulence; 
(2) it must be present in sufficient amount; (3) it must make its inva- 
sion by an appropriate avenue; and (4) it must succeed in reaching 
susceptible tissues. 

The particular place where a virus makes its attack is called the 
primary focus. The focal infection, therefore, is the original point of 
infection. The point of invasion or inoculation may or may not 
develop into a focus. It does not do so in typhus but it commonly 
does do so in wounds. 

The secondary infection may be by a different type of organism 
or by the same one. In epidemiology, it is wrong to speak of second- 
ary infections as meaning new cases which are attributable to those 
due to the original cause of the outbreak. 

There are five main portals of entry by which infective virus can 
establish itself in the body and so cause infection. The five follow: 

1. The alimentary canal or more strictly, the upper opening of 
this canal: the mouth. In this instance the virus enters generally 
with food or drink. The focus of infection is usually established 
beyond the stomach. 

2. The respiratory tract, or more accurately, the nose and mouth. 
The virus generally enters from the atmosphere during breathing, 
but it may be taken in from the hands, conceivably with food, or 
from articles temporarily put into the mouth. The focus of infection 
may be the tonsils, the nasopharynx, the lungs or other parts of the 
breathing apparatus. 






214 EPIDEMIOLOGY 

3. The skin, as when the surface of the body is abraded. 

4. The blood, as when infection takes place by suctorial insects. 
The focus of infection in this case, may be at the point of entrance, 
as with most wounds, or in the blood stream, as usually occurs in the 
case of insect bites. 

5. The genital organs. The focus of infection is the mucous mem- 
brane. 

The body possesses certain normal defenses against infection. 
These barriers may be regarded as of two principal types; those which 
are exterior, or mechanical, and those which are internal or biological. 

The skin is an exterior obstacle of the most substantial character. 
Its effectiveness is believed to be due largely to the existence of its 
epithelial cells. Their texture and thickness vary greatly and are 
suited to offer resistance in proportion to the local need under ordinary 
normal circumstances. Included among the mechanical defenses, 
must be named certain liquid and other discharges which perform 
the office of scouring and flushing away potentially harmful virus. 
Included among those useful substances are the saliva, sweat and 
excretions. 

The biological defenses include the entire group of blood and serum 
reactions. These possess bactericidal powers and are the body's 
last defenses against attack. 

It is possible to express the two elements of virulence and suscep- 
tibility which together produce infection as algebraic quantities 
and the phenomenon of contagion as an equation, thus: 

v + s =1 

In this equation, V is the virus, S the susceptibility and I the 
infection. 

Now, from this equation, it is evident that if either the virus or 
susceptibility increases, the infection will increase also; and conversely, 
a reduction of the virus or susceptibility will lead to a reduction of 
the infection. 

By transposition: 

S =1 - V 

In this case, susceptibility may be conceived as equivalent to. 
infection minus virus. 
Finally : 

v =i - s 

Here the virus is represented as infection minus susceptibility. 
This may be said to represent the carrier state. 

The Interrelation of Infections. — Whether the existence of one 
disease favors or tends to protect against infection by another is a 
point of much interest to the epidemiologist. It has sometimes been 
supposed that two of the acute infections are incapable of existing in 
the same person at the same time. This is not true. There are 



THE INTERRELATION OF INFECTIONS 215 

numerous instances to show that two or more can occur simultaneously. 
There is evidence to show that in certain instances organisms of 
different types can make a successful attack where those of a single 
type are unable to gain successful lodgment. 

It is probable that no general statement can be made which will 
cover the entire case. Pneumonia generally follows a milder respira- 
tory infection; typhoid fever, on the other hand, frequently attacks 
persons not only in the prime of life but at the height of physical 
perfection. 

It would appear that certain microorganisms are able to invade 
the tissues of the body through the healthy mucous membrane, and 
there is reason to believe that intestinal diseases may find a footing 
without any previous impairment of the digestive tract. Exceptions 
to this rule occur with respect to the pus-forming organisms, the 
existence of which upon the surface of the body is well known to be 
common in health. 

How to explain the manner in which pathogenic organisms long 
resident in the mouth and throat produce infection is by no means 
clear. By some it is thought that infection occurs during a temporary 
injury to the mucous membrane produced by a sudden and temporary 
alteration in atmospheric temperature by which a congestion is 
brought about; others believe that the germs may gain entrance 
through minute and undiscoverable injuries. Many hold that there 
is a direct penetration possible even through the healthy tissue. ' With 
these general remarks the subject will be left to the immunologists. 

Some diseases convey lasting, though not necessarily permanent 
immunity. Instances follow: Cholera, typhoid, typhus, scarlet fever, 
measles, smallpox, chicken-pox, yellow fever, mumps, poliomyelitis 
and syphilis. A second attack of typhoid, of scarlet fever, or of 
syphilis or mumps occasionally occurs. Lasting immunity is not 
produced by an attack in the following diseases: Beriberi, dengue 
fever, diphtheria, erysipelas, gonorrhea, glanders, pneumonia, recur- 
rent fever, tetanus and tuberculosis. In some diseases, as malaria, 
reinfection appears to be impossible so long as the individual harbors 
the microorganism. 

Relatively few diseases are transmissible from the lower animals 
to man or the reverse. Tuberculosis of the human type is probably 
never infective to cattle, horses or sheep, dogs, goats or birds. On 
the other hand, the bovine type of tuberculosis occasionally infects 
man, but this is exceedingly rare except among children and then the 
infections are chiefly abdominal or involve the cervical lymph nodes. 
The tuberculosis of birds and cold-blooded animals is not transferable 
to man. 

Among the diseases which occur in man only are cholera, diphtheria, 
gonorrhea, influenza, leprosy, measles, typhoid and typhus, scarlet 
fever, smallpox, poliomyelitis and yellow fever. 

Among the diseases which occur not only in man but in other 
animals are the following: Glanders attacks horses and mules and 



216 EPIDEMIOLOGY 

sometimes sheep, goats and camels. It is essentially a disease of 
animals to which man is also susceptible. The only domestic animals 
which seem to be immune are cattle and rats. Pneumococcus infec- 
tion is virulent for rabbits, mice and guinea-pigs, but relatively harm- 
less for rats, dogs, cattle and sheep. Anthrax, like glanders, is a disease 
of animals to which man is liable. Guinea-pigs, rabbits and white 
mice are very susceptible; rats, horses and dogs are relatively resistent. 
Tetanus occurs in man, cattle, horses and sheep and is rare in dogs 
and goats. 

The Classification of Diseases. — Although it is impossible to 
reduce all the infectious diseases to a brief and comprehensive system 
of classification, it is practicable to gather the more usual ones into 
groups, based upon the possession of more or less common features. 
The most usual basis for this grouping is the kind and degree of their 
infectivity. 

Contagious diseases are those which are so easily transmissible 
that the mere presence of the sick is sufficient to cause others to 
become ill also. Measles, rubella, scarlet fever, smallpox, varicella 
and mumps are in this group. Little or nothing is known about the 
virus of these diseases; how it leaves the body, how it enters, or what 
it consist of. It is generally assumed that it is microbic but its behav- 
ior in the body and out of it are questions which have yet to be put 
on a definite basis. 

In spite of this lack of knowledge, there are many facts of value 
regarding the epidemiology of the contagious diseases. All of them 
occur endemically and sometimes epidemically; all vary considerably 
in the severity of their cases and in different outbreaks; all are more 
prevalent at some seasons than at others; all are difficult to diagnose at 
first; all occur under circumstances which make it impracticable to 
suppress or prevent them; all are crowd diseases; all are. liable to 
complications and sequelae which add materially to their fatality. 
They differ among themselves in prevalence, in severity, in duration, 
in infectiousness, in incubation period and in various other respects. 

The contagious affections are crowd diseases in the sense that 
their occurrence is greatly favored by the crowding of human beings, 
especially in respect to their dwelling places. Some of the diseases 
mentioned as erysipelas, for example, are most common in overcrowded 
hospitals. Others, such as scarlet fever and measles, seldom become 
truly epidemic except in institutions or schools. In some way not 
perfectly understood, the density of the crowding seems to be related 
to the probability of attack. Rubella or German measles is much more 
uncommon than measles, which it somewhat resembles, and is seldom 
seen except in epidemics. Scarlet fever is not only highly contagious 
but is not infrequently carried by a third person and by objects. 
Whereas measles and rubella are contagious chiefly at the beginning, 
scarlet fever is transmissible throughout the attack and in some 
instances long after apparent recovery. 

It is often difficult at first to distinguish between measles, rubella and 






THE CLASSIFICATION OF DISEASES 217 

scarlet fever except for the epidemiological evidence, such as proof of 
exposure to other cases and period of incubation. The chief difficulty 
in controlling the contagious diseases lies in discovering them in time 
to carry out the measures of prevention necessary. These measures 
almost invariably consist of isolation in some form. 

The purpose of isolation is to interpose some obstacle between the 
source of the infectious matter and those persons who are believed 
to be susceptible to it. This obstacle may take many forms. Quar- 
antine is an example of it, as are special hospitals, the use of cubicles 
and masks and the separation of persons as much as practicable 
within the sleeping and living quarters which they must occupy. The 
degree of isolation which is necessary and sufficient for the prevention 
of infection varies with the different diseases. 

A second class of infectious diseases includes the active respiratory 
infections. In this group are the ordinarily unnoticed but important 
common colds, and bronchitis, laryngitis, influenza and pneumonias. 
So prevalent and so fatal are the pneumonias that they deserve to 
be considered separately. It is probable that meningitis should be 
included in this class and possibly poliomyelitis also. Diphtheria 
and tuberculosis although infections of the respiratory type are not 
so distinctly contagious as some of the other diseases mentioned. 

The chief difficulty in the way of controlling the respiratory infec- 
tions lies in the apparent mildness with which they begin and the 
seemingly disproportionate amount of trouble which the preventive 
measures entail as compared with the necessity for them. There 
is this fundamental obstacle also: it is the affected person who 
must exercise the precautions whereas it is the others who are in 
danger of contracting the disease. People can do little for their own 
protection. 

A third class of diseases comprises the intestinal infections. In 
this list are the infectious diarrheas, typhoid fever, cholera and dysen- 
tery. Although they sometimes offer difficult problems of diagnosis, 
the better knowledge which exists concerning their microbic causes 
and their means of transmission by water and food add materially 
to the facility with which they may be recognized as compared with 
the contagious diseases in the two groups already mentioned. The 
first obstacle to suppression of infections of this type lies in the neces- 
sity of keeping food and water free from contamination with human 
excrement. All the infectious diseases could be exterminated if the 
infectious material which produces them could be destroyed at its 
source of origin. This can be more readily done with the infections 
of the intestinal type than with any others. 

There is a long list of diseases which are communicated by insects. 
Among the commonest members of this group are plague, yellow fever, 
malaria fever, typhus fever, trench fever and relapsing fever. 

Finally it remains to mention here a class of infections which differ 
from the foregoing groups by reason of the fact that the extension 
is more particular. Wound infections and venereal diseases are 



21S EPIDEMIOLOGY 

examples. The site of inoculation and the nature of the virus are 
generally understood. Prevention lies in the practice of asepsis and 
disinfection at the site of inoculation. 

Common Vehicles of Infectious Material. — The virus of disease 
seldom passes from person to person by actual contact. It does so 
in the case of venereal* diseases but not often in any other infection. 
As a rule the material is transmitted by some exterior agency. This 
agency, whatever it is, is called a vehicle of infectious material. If 
the passage is very short in time and space, the infection is called 
contact. 

In respiratory infections the most common vehicle is probably the 
air. Sometimes the germs are thrown out to the air direct, as by sneez- 
ing; sometimes it is present with dust from floors, bedding or other 
objects which have accidentally become infected. When the atmosphere 
thus becomes charged, it is consequently dangerous. Theoretically and 
practically the danger increases much more rapidly than the distance 
from the patient decreases. 

Over what distance infection can occur through the air probably 
depends upon the amount of virus in it. This in turn depends upon 
the fineness into which the minute masses are divided and the weight 
of these ultimate particles. If the air was still they would quickly 
subside, but the air is never perfectly quiet. The infective material 
remains suspended for the same reasons that dust is suspended and 
its movement follows the same laws which apply to the aerial trans- 
mission of dust. If this is true, there is here an explanation why the 
aerial transmission of disease is always short — there are few authori- 
tative cases in which it has been known to extend beyond the room 
in which the patient has been confined. Badly ventilated barracks, 
hospital w r ards and other inclosed spaces, even though large, become 
charged with infectious matter because it is not only produced but 
confined there. Ventilation affords one of the most useful means of 
preventing aerial infection for it provides both for the dilution of the 
poison and for its removal. 

It is perhaps unnecessary to say that air-borne diseases belong 
chiefly to the respiratory type and that the cases which develop are 
usually sporadic. 

Water, milk and other beverages commonly act as vehicles for the 
virus of intestinal infections. These liquids no doubt often receive 
the germs of respiratory diseases, but it is not known that they ever 
lead to respiratory infections. 

Water becomes contaminated generally through pollution by the 
drainage of some receptacle of human excrement. Milk most often 
becomes polluted through impure water and by the hands of milkers. 
The type of outbreak produced by milk or water is generally explosive. 
Infection by water may, however, be sporadic. Many cities with 
polluted water supplies have continuously high typhoid rates. 

Food sometimes leads to infection, but in view of what it would 
seem reasonable to expect, it is surprising that so few instances of 



TABULATIONS AND GRAPHS 219 

it are on record. It would seem that bread and fruit as well as other 
articles of food which are sticky, handled a good deal and often in a 
position to be coughed upon and eaten without subsequent cooking 
must frequently serve as vehicles of infectious material. 

Common objects, familiar to everyone, handled by everyone, help 
to spread diseases by serving as temporary storage points and exchange 
places for microbic poisons. These objects include door-knobs, the 
arms of chairs, pencils, car straps, dirty towels and drinking cups. 
Whatever is very near to the person who is coughing and sneezing 
germs into the air probably becomes contaminated. 

The hand plays a prominent part in the spread of disease. Its 
structure and its functions perfectly suit it for this office. Commonly 
the germs get upon the hands directly from the excretions and these 
microbes are then transferred to articles which gain entrance to the 
mouth. 

The part which insects play deserve notice. Some diseases, as 
typhus and malaria, could scarcely occur without the intervention of 
insects. The common house fly has been charged with spreading 
typhoid but aside from its probable complicity in special instances, it 
is doubtful whether it is as guilty as it is made out to be. 

Briefly then, the vehicles which transmit infectious matter are 
various and their effectiveness in causing disease depends upon the 
ways in which the germs are thrown off from the body and the way in 
which they must enter it. Respiratory diseases are probably most 
often transmitted by the air, intestinal diseases by food and drink 
and infectious diseases of the blood through the skin by insects and 
wounds. 

Tabulations and Graphs. — Under the heading of Methods and 
Resources, it was pointed out that the foundation of all epidemiological 
work was the collection of facts. It was stated that these facts must 
be gathered with the greatest care, that they should be of proved 
accuracy and that it. was necessary for them to be properly arranged 
in order to yield the maximum of information. 

Much will depend upon the arrangement of the collected data. A 
carefully considered system of tabulation should be devised in order 
that the very bulk of the material may not obscure a clear view of 
the conditions which the data represent. 

The elements which are most commonly represented in statistical 
studies as, for example, an epidemic of a particular disease, are the 
location of the cases, the duration of the outbreak, the total number 
of cases, and the fatalities and various details relating to these ele- 
ments. By the proper arrangement of the data may be discovered 
the concentration of the infections within geographical and time limits, 
the direction and rate of spread and many other points of interest. 

It will generally be found best in the long run to prepare many 
relatively small tables rather than a few large and concentrated 
ones. Groupings and regroupings should be made in order to see 
what facts these combinations reveal. The clerical work should be 






220 EPIDEMIOLOGY 

done with great neatness; the typewriter and every other mechanical 
aid should be employed. Large numbers of figures should be sepa- 
rated by spaces rather than lines. Complicated headings should be 
avoided; lines of figures should be divided into groups of five to aid 
the eye in following the lines; the data should be worked up as fast as 
it is collected and not left to some future date for study. 

In studying a large map of data, it will often be desirable to make 
use of diagrams. One class of graphs may have to do simply with 
the illustration of the tabulated data. Another will have for its 
object the analysis of the tabulations. Tabulations should always 
be made as the basis for diagrams. 

Spot maps are convenient as a means of visualizing certain facts 
which cannot well be comprehended otherwise. A spot map is simply 
a large-scale map upon which locations, as the position of cases, are 
suitably marked. The most simple system of marking is to stick a 
pin into the place where each case has occurred. Colored pins, espe- 
cially made for such purposes, are obtainable; the color indicates the 
character of the disease or its fatal consequence or its recovery. This 
may show at once the centers from which other cases have radiated, 
or from which other cases may be expected. A development of this 
scheme is the employment of long pins, each of which carries a tag 
upon which various particular facts are compactly written as, for 
example, the number of the case, its date of onset, etc. A casual 
inspection of the map at once shows the distribution of cases and a 
closer inspection brings out many other points. 

Epidemic curves are often employed in connection with spot maps. 
They can be easily and quickly plotted and they show the increasing 
or decreasing tendency of the outbreak every day or week. It is cus- 
tomary to plot such curves by using a horizontal scale to indicate 
the time intervals and the vertical ordinate, the incidence of cases 
or their rates. For this purpose standard section paper can generally 
be had at stationery shops, ruled to inches and tenths. The length 
of the smallest division of the horizontal and vertical scales must 
depend upon the conditions of the epidemic. The vertical scale 
should always be much greater than the horizontal; it should be 
great enough to emphasize the large variations without attaching 
undue importance to the little ones. It is advisable to make various 
plottings in order that the work when complete will be simple and 
impressive. It must not in any way be confusing or cramped; it will 
usually be worth while to have the work done by an engineering or 
architectural draughtsman. 

Instead of the curves just described, it is often desirable to use a 
still simpler form of diagram. A series of lines or bars or columns 
represents the number of cases from week to week or day to day. 
These should almost always be drawn from the bottom up and seldom 
from one side of the diagram toward another. The diagrams may be 
made of a size suitable for wall display or for desk work. If for the 
desk or to accompany a typewritten report, the diagrams should 



EPIDEMIC FIGHTING 221 



be the size of a sheet of letter paper, or twice that size and folded 
once. Unduly long, bulky, awkward or clumsy diagrams often 
defeat their own ends for they are too inconvenient to be examined. 

Where feasible, it is well to have a small condensed table of data 
to accompany the curve or diagram. No graph is likely to be suffi- 
ciently accurate to permit figures to be taken from it. Graphs are 
intended to indicate general tendencies; resort should be had to 
tables for detailed facts. 

Epidemic Fighting. — The best time to take arms against an epidemic 
is before it occurs. Under no other circumstances is the old adage 
more true that prevention is better than cure. In fact, there is often 
no cure for an epidemic in full career any more than there is for one 
of the cases of disease which compose it. It can often be prevented — 
it can sometimes be restricted — but once under way it can rarely be 
stopped short. 

Epidemic fighting is a popular term which is applied to work intended 
to limit the spread of a contagious disease which has already broken 
out or is thought to be about to do so. It is a prime necessity that 
the undertaking be placed in competent hands in order that the 
campaign shall be well prosecuted. The work should be pushed 
with energy, directness and thoroughness. Ample authority must 
be given and pecuniary resources must be made available at the 
outset. It is highly important that wherever possible a laboratory 
for clinical and bacteriological control shall be available. 

The details of much of the work of epidemic fighting will generally 
have to be attended to by persons of little or no training in this sub- 
ject. In consequence of this fact only simple procedures whose 
principles can easily be grasped should be employed. It will often 
be found that the cause of the epidemic lies in a set of conditions the 
existence of which is not so much unknown as uncorrected. 

A campaign against an epidemic should embody the following 
features : 

(a) Education. — Every competent person available should be induced 
to cooperate in the work. Courses of action should be prepared for all 
those who are to assist in arresting the spread of the disease : physi- 
cians, nurses, housekeepers and all who may be in danger or may 
endanger others. Instructions should be given by lectures, and 
where feasible, in printed form. There should be no secrecy about 
the name of the disease, its character or its progress. 

(b) Notification.— Cases, deaths and other data needed by the 
central authority should be specified by him and reported fully, 
accurately and immediately. 

(c) Isolation. — The sick and other sources of the infective virus 
should be so dealt with in hospitals or homes as to make it as nearly 
impossible as may be for the virus to pass to those who may be sus- 
ceptible to it. Efforts should be made to detect those who are immune 
by reason of a former attack or otherwise. 



222 EPIDEMIOLOGY 

(d) Vaccination. — In those diseases in which artificial immunization 
is practicable it should be widely practised. 

{c) I nspcci ion. — It will be necessary to see if the lessons given in 
the educational campaign are being applied and it will be desirable 
to supplement those lessons. Inspectors possessing tact and practical 
ability will be needed to show how to do the things which are necessary 
and to report upon the condition. 

(/) Sanitation. — Improved methods of cleaning and sanitating 
dwellings, streets, shops and public conveyances will strike a popular 
chord and will be beneficial in many ways. 

(g) Disinfection. — By disinfection is meant the destruction of 
infectious material. It may be effected by chemicals, fire, sunlight 
or otherwise. Disinfection should be carried as near as possible to 
the source of the virus. It must be thorough — there is no such thing 
as partial disinfection. Properly employed, soap and sunlight are 
among the best disinfecting agents. 

(h) Investigation. — The most useless thing to do in fighting an 
epidemic is to make an elaborate, scientific investigation of it. Some- 
times, unfortunately, this is the only thing which is done. Investi- 
gations of one sort or another may be necessary from the outset, but 
these should be carried on for practical purposes only. The point 
should be kept consistently in mind that the work in hand is to limit 
the outbreak. 

(i) Report. — The report is the last thing to complete but not the 
last thing to begin. Preparations for it should be made as soon as 
anything is done. By so doing the campaign will be kept in order, 
its various features will assume a just proportion and a correct per- 
spective will be formed of the situation. All data should be tabulated, 
illustrated and digested as rapidly as it is collected. 

In practical work of investigating and managing epidemics it often 
becomes necessary to know for how long after exposure a person may 
be in danger of attack. This interval is called the incubation period. 
It is not the same in all diseases nor in all cases. The fact that it 
varies with different diseases sometimes affords a useful clue to the 
diagnosis. 

Apart from the minor respiratory affections, the shortest period of 
incubation among the contagious diseases occurs in scarlet fever. 
In scarlet fever the interval may be as short as a day or as long as a week; 
generally it is about three days. In erysipelas the interval is from 
three to ten days. Diphtheria generally takes from two to five days 
to develop but sometimes longer. 

Measles has an incubation period of from one week to nearly three 
weeks; oftenest about twelve days. Rubella, or German measles, 
generally takes longer than measles to develop; ordinarily from two 
to three weeks. 

The limits for mumps are usually ten and twenty days; for chicken- 
pox from ten to seventeen days and for whooping-cough from one to 
three weeks. 



EPIDEMIC FIGHTING 223 

Among the great epidemic diseases the shortest periods of incubation 
are: Cholera, two to six days; plague, two to eight days; and typhus, 
four to fourteen days. Typhoid may require anywhere from one to 
two weeks, sometimes more, and smallpox from eight to fifteen days, 
but usually about twelve. 

With reference to the means of transmission, it is convenient to 
remember that practically all the diseases which one is likely to 
meet may be transmitted by contact and by carriers. Practically 
all may be conveyed for very short distances by the air. Among 
the diseases of the respiratory type, which are sometimes transmitted 
by food, should be included scarlet fever and tuberculosis and perhaps 
diphtheria and erysipelas. 



CHAPTER VI. 

SANITARY SURVEYS. 

By W. L. DODD. 

Sources of Information in General. — Two sources of information 
are essential in order to obtain an accurate picture of the sanitary condi- 
tions of a community. For convenience, these two sources of informa- 
tion may be outlined: first, a general picture of the community itself 
and, second, the factors affecting life wastage, together with measures 
for their control. 

A historical review of the progress of sanitation within the com- 
munity; commercial activities and their relation to public health, and 
a general description of the population, its composition and changes 
may be considered as coming under the first group. 

Under the second group may be included such subjects as a study 
of the general death-rates; death-rates for specific causes; infant 
mortality, the public water supply, milk supply, disposal of excreta, 
problems of industrial hygiene, housing conditions, sanitation of 
schools, markets and streets, and the disposal of wastes and garbage. 
Beside the specific measures of conservation for the various factors 
just mentioned, there are general measures of control, such as the 
powers and duties of the Board of Health, the budget of the Health 
Department, publicity and education, drainage and mosquito control, 
rat eradication, and the removal of fly breeding places. 

Historical Review on Progress of Sanitation. — A study of the 
progress of sanitation in a community is apt to reveal three distinct 
phases: the period when the individual alone was responsible for 
his own protection, the period when attempts were made by various 
individuals or organizations to introduce and maintain sanitary 
measures, and finally, the period when an organized Health Depart- 
ment came into control. Each of these phases should be carefully 
studied, together with their effect on the sanitation of the community. 

History of Commerce and its Effect on Sanitation. — The effect of 
commercial expansion or decline may be illuminating, especially in the 
earlier days; progressive health measures being in vogue as long as 
prosperity existed, but abandoned with the onset of commercial inac- 
tivity. In port cities, the effect of quarantine on commerce should be 
noted, also the effect of commerce on quarantine. 

Population Changes. — A study of the population should show the 
changes over the various decades with an indication of the effect of 
industrial enterprise on population movements. Observation should be 
made of changes in the composition of the population during the various 
decades by a study of the community according to the various main 



GENERAL DEATH-RATES 225 

color and nativity classes. Indications of an accelerated tendency 
toward Americanization might be shown by a growth of the native 
born of native parentage, accompanied by decreases in the foreign 
born or native born of foreign parentage. The general death-rates 
should be carefully studied with reference to population changes. An 
apparent acceleration of the total population growth might be due to 
marked decreases in the general death-rates and not to immigration. 
On the other hand, the general death-rates might be influenced by 
increases in race stocks with a known tendency toward high mortality- 
rates. 

General Death-rates. — The study of the general death-rates may well 
be supplemented by a historical table of the principal causes of death 
in the early days of the community, thus making possible interesting 
comparisons between past and present tendencies in the mortality-rate. 
This study should include not only the principal causes of death but 
any marked seasonal mortality for a specific disease or group of diseases, 
bearing in mind that several factors may produce changes in published 
death-rates, such as changes in the classification of the causes of death, 
possible improvements in the diagnostic ability of physicians and the 
education of physicians to better reports and descriptions of causes of 
death, through the efforts of Federal, State and city registrars or 
statisticians. It is possible that high temperature may directly or 
indirectly affect the virus of smallpox with a lowering of the death- 
rates during the warm summer months. Harsh weather conditions 
may influence mortality-rates for various respiratory diseases. Diseases 
transmitted by the mosquito, as malaria and yellow fever, are affected 
by a lowering of the temperature and its attendant destruction or 
hibernation of the insects. It is also suggested that an examination of 
the general death-rates be made according to sex, race and age. 

Before entering into a discussion of the present mortality-rates of 
the community, it is well to consider the effects of various sanitary 
reforms on specific diseases. For example, improvements in the public 
water supply or the method of sewage disposal might be productive 
of changes in the typhoid death-rates. The introduction within the 
community of specific biologicals, curative or prophylactic products, as 
diphtheria antitoxin or smallpox vaccine, would radically influence the 
death-rates for the respective diseases. The installation of an ade- 
quate system of drainage or the prosecution of a vigorous anti-malarial 
campaign should be reflected in the case and death-rate of the disease. 

The present status of the community death-rates should be based 
on a study of the general mortality-rates, for a three-year period, 
according to color, sex and age. It is not wise to use figures for a single 
year in computing death-rates as the year may not be typical. Some 
unusual condition might be productive of a low death-rate or a severe 
epidemic might increase the death-rate above the average. Intercity 
comparisons may also be made, such comparisons being made with 
due regard to the composition of the respective communities according 
to color, sex and age. It is apparent that the death-rate of a com- 
15 



220 SANITARY SURVEYS 

nuinity containing excessive amounts of children and young people 
with high death-rates from the communicable diseases could not be 
compared with a community made up largely of the middle- and old- 
age group with high death-rates from the degenerative diseases of adult 
life, unless the age composition in the two communities was stated or 
otherwise allowed for. In the same way, communities with large negro 
populations would have higher death-rates than those made up of the 
Caucasian race. Males have higher mortality-rates than females 
possibly because of a greater exposure to the health hazards of 
industry. 

Other factors which may influence the death-rate may be social or 
economic in origin. Low wages and high living costs may be productive 
of poverty and a lack of proper medical attention and care. An 
inherited tendency toward a weakened constitution through successive 
generations of decadent and degenerative stock may also be considered. 

Death-rates for Specific Causes. — The death-rates for specific 
causes should include the communicable diseases of childhood, tuber- 
culosis, typhoid fever, pneumonia, malaria and any other disease which 
is a potent factor in the life wastage of the community. It may be well 
to consider death-rates for the degenerative diseases of adult life. 

The first consideration in analy^ ing a specific death-rate, as that of 
a communicable disease, is a brief statement of the prevalence of the 
disease in the past and present, commenting on facts which have con- 
tributed to its introduction within the community, also whether the 
disease is increasing or decreasing in its incidence. 

The crude death-rates may then be presented for a three- or five-year 
period in comparison with other cities, such comparison being made, if 
possible, on a basis of color and age although it must be admitted that 
it is difficult to obtain statistics on the distribution, according to color 
and age. Intercity comparisons of mortality according to sex and age 
of the total population are found on pages 16 and 17 of the 1911 Mor- 
tality Statistics Report of the Bureau of the Census and may be helpful 
especially where the age and sex distribution has not materially changed 
since the 1911 census report. 

A differentiation between resident and non-resident deaths is also 
difficult to obtain for two reasons: First, because of an inability to 
obtain reliable data as to the fact of residence or non-residence and, 
second, because of the lack of an adequate definition of a resident. 
Some statement of the number of resident and non-resident deaths is 
indicated, however, where it is known that a large number of non- 
resident deaths occur in local hospitals or other institutions for the 
destitute and sick. 

The death-rates for the particular disease under discussion may next 
be shown according to color, age and sex for a five-year period. 

The reporting of cases by physicians may then be studied. As an 
example, select the death certificates of a reportable disease, as typhoid 
fever. For each death certificate a case report should have been re- 
corded. The proportion of case reports filed to the number of known 



INFANT MORTALITY 227 

fatal cases (death certificates) is an excellent index of the manner in 
which physicians are reporting. Furthermore a comparison of the 
dates on the case reports and death certificates is a check as to whether 
reporting is done within the prescribed legal limits, or as to the cor- 
rectness of the original diagnosis. Case reporting is usually poorly 
done; so it is difficult to ascertain reliable fatality rates for diseases 
from Board of Health case reports. In a similar manner, fatality 
rates cannot be calculated from hospital returns because of the large 
number of moribund cases which they frequently receive. 

It is well to examine the monthly records of case reporting for the 
communicable diseases and determine the possible occurrence of an 
epidemic indicated by marked increases in the case reports over what 
is considered as the normal average. Where the public milk supply 
is not pasteurized, the possibility of milk-borne epidemics of typhoid 
fever, scarlet fever, septic sore-throat and diphtheria should be borne 
in mind. Carriers or contact cases may exist for several of the 
diseases and be potent factors in distributing the infection. 

Special attention should be paid to certain factors in connection with 
several of the diseases. 

Difficulty will probably be encountered in obtaining figures to 
calculate rates for the venereal diseases and the discussion may limit 
itself to the consideration of the subject as a social problem in general 
and its control. Figures for syphilis, locomotor ataxia and general 
paralysis of the insane may be grouped and considered under one 
heading. 

High mortality-rates for tetanus of the newborn suggest an inquiry 
as to the supervision and control of obstetrical service. 

The health of food handlers, relation of flies and privies and the purity 
of water supplies should be investigated in the case of typhoid fever. 

Malaria suggests a study of mosquito breeding areas, examination 
of the blood of individuals in infected districts and the screening of 
residences or other protecting devices against the mosquito. 

Tuberculosis should be studied to ascertain whether there is a suffi- 
cient number of hospitals and sanatoria for advanced and incipient 
cases and whether visiting nursing service exists for the supervision 
of home cases. Dispensaries, open-air schools, housing conditions, 
the milk supply, medical school inspection, industrial dust and the 
educational work of tuberculosis associations are other factors for 
investigation. 

Infant Mortality.— Infant mortality-rates ' cannot be accurately 
calculated unless there is accurate birth registration. Three methods 
of checking birth registration are suggested : First, birth-rates should 
not exhibit violent fluctuations from year to year. Second, birth-rates 
should not be markedly lower than the average birth-rate for other 
communities with similar color and age composition. Finally, determine 
whether the births were registered of all infants who died under one 
year. This necessitates checking back the death certificates of the 
infants in question against their birth registration cards. 



228 SANITARY SURVEYS 

Knowing the effectiveness of birth registration the infant mortality- 
rate can be calculated by color and for the various months. Infant 
mortality-rates may also be ascertained for the various quarters of the 
first year of life to discover at which quarter mortality is highest. It is 
well to subdivide the rates for the first quarter according to deaths 
under one day, of the first day, less than the first week and less than the 
first month. Considerable information for an infant mortality cam- 
paign may be secured if the infant deaths can be grouped into two 
series : deaths of infants caused by influences before birth and influences 
affecting the mortality-rate of infants following birth. A suggestion 
is offered in a classification which has been employed by Terry and 
Schneider distributing infant deaths according to prenatal and post- 
natal causes, the residuum being classified as due to all other causes. 

The first group, prenatal influence, embraces deaths from prema- 
turity, congenital debility, malformation and other causes peculiar 
to early infancy. The second group; postnatal influence, includes 
deaths from diarrhea, pneumonia, communicable diseases, other re- 
spiratory diseases, tuberculous affections, tetanus, and other postnatal 
causes difficult of classification. All remaining deaths are included 
under the third group, — all other causes. A careful study of infant 
deaths according to these various influences should indicate 1 he methods 
and point of attack of an infant mortality campaign. The information 
is best obtained by case histories. The writer has used a somewhat 
similar classification: deaths ascribable to conditions preceding or at 
birth, and deaths following birth and largely attributable to environ- 
mental conditions. Curves plotted on the basis of the period when 
death occurred will show for "birth" causes a high sharp peak during 
the first few hours following birth, dropping away to a negligible factor 
within the first six months. On the other hand the "environmental" 
curve will show a gradual but slow rise during the first few weeks fol- 
lowing birth with an abrupt rise by the end cf the first month. The 
peak occurs in the second quarter of life, but is high in remaining 
quarters. In other words, the bulk of the "birth" deaths fall within 
the first month, after which "environmental" deaths become prominent. 
The plotting of two curves is more graphic and instructive than a 
single composite curve for all causes of infant mortality. 

Several medical, physical and economic factors influence infant 
mortality, such as the character of the obstetrical service, the mode 
of feeding, the age of the mother, whether the pregnant mother worked 
before confinement and the wages of the father. Heat and humidity, 
the seasonal distribution of deaths and the home environment are very 
important factors to be studied. 

Interesting comparisons can be drawn by computing infant mor- 
tality-rates based on the nature of the birth attendant, whether a 
physician or midwife. Comment should be made on the supervision 
and control of midwifery. Confinement charges of midwives and 
physicians may be interesting in indicating a tendency to patronize 
the group with the lower rates for confinement. 



MILK SUPPLY 229 

Tables may also be constructed showing the relative mortality 
among breast- and bottle-fed infants. Tables of this character have 
been published by Dr. L. I. Dublin in an article entitled "Study of 
Infant Mortality among Infants of Fall River" and an article by Dr. 
W. H. Davis on "Mortality of Breast- and Bottle-Fed Infants." 

The effect of hard labor on the pregnant mother before confinement 
is well known. A study should, therefore, be made of the entrance 
of women into the industrial life of the community and the effect on 
infant mortality. 

The wages of the father are important. Where the births of a 
community are largely among the laboring classes, a high infant 
mortality-rate may be expected when the wages of the father are not 
sufficient to provide adequate care and nourishment for the young 
infant. 

Measures directed to the lowering of infant mortality-rates may be 
sought under two main sources — public and private — and will consist of 
infant welfare organizations, lying-in hospitals, clinics and nursing or 
medical service. Each of these factors should be carefully studied to 
determine the influence their program is having on a reduction of the 
infant mortality-rate. 

Water Supply. — The first considerations of a public water supply are 
safety and adequacy. If it is a surface water as a river, freedom from 
sewage pollution should be noted and if from an impounded stream or 
pond, the danger of surface washings from privies should be heeded. 
Water from underground sources is usually safe except in a limestone 
region. The question of adequacy depends not only on normal con- 
sumption but also on sudden strains on the service as an extensive fire. 

Water is purified by storage or by filtration. If stored the length of 
storage should be noted, especially if the public supply is from two 
sources where it may be shown that the period of storage is not suffi- 
cient in each instance. The method of purification, where filtration 
is resorted to, should be described in detail. Chemical disinfection 
should also be noted. The reservoir, filtering and pumping service 
should be sufficient to provide for more than the average daily con- 
sumption. 

The distribution system should be studied to determine whether 
the bulk of the built up area is connected to the public water supply 
and not dependent on other sources, possibly polluted, for a potable 
water. 

Communities may have private water systems either of an industrial 
character as water supplied to homes of industrial operatives, or pos- 
sibly systems maintained in isolated subdivisions by private owners. 
Bottled waters may be sold to a considerable extent, or wells frequently 
used. All of these private sources of supply should be carefully inves- 
tigated for their safety and, in the case of bottle water, the sterility 
of the container should be questioned. 

Milk Supply. — The study of the milk supply may be started with 
a statement relative to the ordinances controlling the supply and the 
legal machinery for their enforcement. 



230 SANITARY SURVEYS 

The next step is the production of milk at the farm, the methods 
employed and equipment used, bearing in mind that essentials in the 
production of clean milk are clean cows and milker's hand, sterilized 
utensils with small openings and prompt cooling. The health of cows 
and milkers is also to be considered and the opportunity of contami- 
nation through flies and privies. 

The problem of transportation should be considered from the 
standpoint of the distance of dairies from the city, the methods and 
rapidity of transporation and the temperature of the milk in transit. 
If considerable quantities of milk are found to sour in transit, a study 
of the reasons for this economic loss is in order. 

The location and surroundings, cleanliness, methods and equipment 
of city milk plants, together with the rapidity of handling is next to 
be considered. The perfection of pasturization is important. Every 
drop of milk should be maintained constantly for one half hour at 
145° F. Apparatus should be clean. Cursory washing and steaming 
is insufficient. Vigorous scrubbing and prolonged heating is necessary. 
If the cleansed apparatus still retains a film of grease, high bacterial 
counts may be anticipated. 

The number and hours of delivery and temperature on the wagon 
are points in the distribution of milk. During summer weather or in 
southern cities, deliveries between midnight and sunrise may afford 
several hours' incubation at a warm temperature while the milk is 
standing on the porch. Other sources of distribution are stores and 
milk depots and these should be visited to determine the source of 
supply and the methods and equipment for handling. 

Market requirements may be considered for the consumption and 
standards of different grades as raw, pasteurized, graded, and certified 
milk. 

Finally comes a consideration of the control of the milk supply 
through bacterial tests, chemical tests, and inspection service. 

Disposal of Excreta. — A sewage system is needed for two reasons: 
protection of public health and the convenience of the householder. 
It must meet two requirements: quick removal and safety of disposal. 
Sewerage systems of the water carriage type are known as separate 
and combined, separate when storm water and household wastes are 
handled through two services and combined when one system takes 
care of both supplies. The combined type requires larger pipes and 
steeper grades. Hence, a first consideration is the topography of the 
land and the requirements to be met. The amount of sewage and any 
problems arising because of trade wastes are to be considered. 

Next, a detailed description of the collection service itself with a 
consideration of the maintenance of the service such as flushing, clean- 
ing and ventilation of pipes. Determine whether the tie-in between 
the sewer line and the house connection is under official supervision 
and control. The reduction of soil saturation and the provision for run 
off of severe storms may be heeded. 

The sewage must be treated and disposed of with safety to the 



INDUSTRIES AND INDUSTRIAL HAZARDS 231 

particular community, or any adjacent. This is especially true where 
the method of disposal is by the dilution method. A local nuisance 
must not be created. Successful disposal by the dilution method 
requires straining and screening to prevent coarse floating particles, 
swift running streams of fair size, and the absence of coves to receive 
deposits of sludge. Visit the sewer out-falls and determine if disposal 
is safe and at all times adequate. Collect and test the effluent for its 
stability and number of B. coli. 

Private sewerage systems as privies or cesspools, or some small system 
as of a hospital, industrial institution or isolated sectors, must be 
carefully ascertained and investigated for their safety and maintenance. 

Industries and Industrial Hazards. — This section may well be 
divided into two main parts : a study of the city as an industrial center 
and a survey of the industries for their industrial hazards, and preven- 
tive measures of control. 

The study of the city as an industrial center should start with a 
statement as to whether it is primarily of the industrial type or is more 
dependent on trade and commerce. The geographical location may 
determine whether the type is industrial or commercial. The next con- 
sideration is the location of the industries of the city whether grouped 
together in localities within the city or scattered along the city out- 
skirts. The history of the community's industrial progress should be 
stated and studies made of the value of products, size of establishments 
and an analysis of the working population by color, sex and industry. 
The reports of the Census Bureau will prove of service in connection 
with the studies of value of product, establishments, and working 
population. 

Having a mental picture of the industries of the community, a 
detailed study should be made of the industries themselves. First is a 
consideration of the labor ordinances and the machinery for their 
inforcement, with comment as to their efficiency, adequacy, and com- 
pleteness. Where industrial accidents are reported fully and the 
number of exposed employees is known, death-rates for different types 
of fatal accidents can be calculated, as well as severity and frequency 
rates for non-fatal accidents. Factories should be inspected for the 
adequacy of machine safeguarding and the general attitude noted of 
the plant working force and executives to safety organization. The 
fire hazard of factories should be studied from three angles; (1) Regu- 
lations or methods toward the reduction of the fire hazard; (2) the 
installation of fire-fighting apparatus and (3) adequate and sufficient 
exits from the building in case of fire. Health hazards of the factories 
may be conveniently presented in four main groups: those exposing 
the workers to poisonous fumes, to industrial dust, to fatigue and to 
temperature extremes. At the time of inspection, insanitary features 
of the factory should be noted as well as the occupational hazards. 
The compensation laws, or the method of compensation, for industrial 
hazards, among the different factories should be carefully studied and 
criticized. Preventive medical work should be determined, as entrance 



232 SANITARY SURVEYS 

medical examinations, periodical re-examinations, rest rooms and 
nursing. 

Welfare work must be considered as lunch and recreation rooms, 
vocational training of employees, provision of medical and dental 
services, commissaries, insurance, service annuities, stock purchase 
plans and building or remedial loans. Child labor in the factories 
should be noted and the child labor laws examined for any defective 
construction. Wages for both skilled and unskilled labor, working 
hours, regularity of employment, employment bureaus and living costs 
are other factors for thought. 

Housing Conditions. — The first consideration is the growth of the 
city and the races which have contributed to its increase. Growth 
may be found slow and regular, or rapid and abrupt. The growth 
should be studied by different epochs, as agricultural, commercial, and 
industrial, paying attention to the effect of each epoch on population 
increases. 

A careful study of the traits and habits of the early settlers of the 
community will prove interesting. Unless marked changes have 
occurred in the population due to the influx of foreign race stocks or 
interstate migration, the traits and habits of the present generation 
will often show a similarity to those of the original settlers. 

The next point of interest is the homes of the city, the types con- 
structed by the early comers, and present tendencies. Different race 
stocks may affect housing conditions for better or for worse. Certain 
races will not build up property but buy and wring profit from the 
investment. Other races are builders and take pride in their property. 
The tendency of some races to group together may lower real estate 
values in their vicinity. The fine old family mansion of yesterday 
through successive stages of neglect and decay may become a rooming 
house for the recently arrived immigrant. 

How is the land used? Are homes crowded close together with 
cluttered up back yards filled with sheds thus increasing the fire risk, 
or do broad open spaces abound? What influence is exerted by drain- 
age conditions, or land topography, in forcing homes to build close 
together on the high plateaus? Is the supply of buildings plentiful or 
are inhabitants practically forced to live in dirty or insanitary dwell- 
ings because of a lack of vacant property from which to make a better 
selection? What is the best method of increasing the supply of homes? 
Should new areas be developed or a more intensive cultivation be made 
within the present confines? These are all questions to be considered 
as a part of the housing situation. The rentals of various classes of 
property should also be investigated. 

The sanitation of the home depends on many factors as the purity 
of the water supply; is it from a safe public supply or the dangerous 
shallow dug well? How is sewage disposed of, by a connection to the 
public system or the open unscreened privy vault? The question 
of damp, dark, gloomy and poorly ventilated rooms should be given 
attention for its possible connection to the local tuberculous problem. 



SANITATION OF MARKETS 233 

Of lesser importance from a health viewpoint is the disposal of garbage 
and housekeeping tendencies in general. 

Finally comes a consideration of the construction and financing of 
buildings, whether homes are erected as single units at a time by 
individuals, or developed in groups by subdivision, and whether they 
are built on a cash-payment basis, or through the loans of a building 
and loan association. 

Sanitation of Schools. — The number of schools, public, private 
and parochial, and their enrolment should first be considered, following 
this with a consideration of the school building itself. Possibly two 
general types will be found, the older buildings of the system and the 
more modern types. Both types are to be studied as to the number of 
rooms and floor space per pupil, the protection against fire, as exits, 
alarms, and fire drills, and finally, the freedom from dampness and 
lighting facilities of basements especially if they are employed as class 
rooms. The purity of the water supply is to be questioned and if 
bubbling fountains are in use notice whether the jet of water is thrown 
several inches into the air or if the force of flow is so weak that the pupil 
must practically place the mouth on the nozzle of the apparatus to 
obtain a drink. Notice whether the disposal of sewage is adequate 
and safe. The toilet should be clean, free from odor and accessible 
to the children without exposing them to inclement weather. There 
should be about five toilet seats for every one hundred boys and seven 
for the same number of girls. 

The floors of classrooms should be constructed of material which is 
easily kept clean. In this connection, it may be stated that dry clean- 
ing or dusting should be prohibited. Cleaning should be completed at 
least an hour before the children enter the building. Walls should be 
of smooth surface, and tinted with some color which does not absorb 
too much light and is not hard on the eyes. White plastered walls, 
especially those on which bright sunlight falls, may be productive of 
eyestrain. Desks and chairs should be of the adjustable type and 
fitted to the children at the beginning and middle of the school year. 
Blackboards should be located so as to be easily seen and not placed in 
dark corners or between windows, the latter arrangement producing 
a glare hard on pupils' eyes. Windows should be at the left and rear 
of desks. Window shades should pull up from the bottom as the best 
and most light comes from the upper part of the window. The glass 
area of windows should be close to one fourth the area of the classroom 
floor space. No desk should be more than twenty feet from the source 
of light and the lower edge of the window should be above the visual 
level of seated pupils. Rooms should be well heated and ventilated, 
each teacher being held responsible for the condition of her individual 
room. 

Sanitation of Markets. — Markets of good sanitary construction 
must be easily cleaned. Floors and inside walls should be of non- 
absorbent material and of smooth surface which will clean readily. 
Light and ventilation should be adequate. Hot and cold water should 



234 SANITARY SURVEYS 

be provided. Large markets should have fly-proof public comfort 
stations. Garbage cans should be tightly covered and frequently 
removed for emptying. Every effort should be made to keep flies 
out of the market. Doors opened from the outside by pulling and 
electric fans throwing a current of air toward the door may prove of 
value. Food must be protected from " fingers, flies and filth" and be 
sufficiently refrigerated to insure its preservation. The modern way 
of protecting exposed perishable food is to place it close to refrigerated 
coils under glass. In this manner, the customer can view the food which 
is kept cool and protected from dust, investigating fingers, or the 
inquisitive fly. When studying the sanitation of markets the question 
of the effect of high food prices on the community health should be 
considered. If prices are high, the consumer will purchase goods of 
an inferior quality because the price is cheap. Malnutrition with its 
attendant evils may thus be produced especially among children. 
Public markets successfully and efficiently operated may be of help 
in lowering food costs. To be successful, there should be a demand 
for them. They should be adjacent to tributary sources of supply, 
conveniently located, constructed and equipped with due regard for 
sanitation, and so managed as to operate at cost or but a slight margin 
of profit. 

Street Sanitation. — Describe the equipment of the street cleaning 
service and follow this with a detailed description of the methods of 
street cleaning as adapted to the different types of paved streets. 

Disposal of Garbage. — State first the early methods of disposal 
and the reason they were abandoned and follow them with a brief 
review of the municipal ordinances relative to garbage collection and 
disposal. The frequency and adequacy of the collection service should 
be noted and the method of disposal described in detail with criticism 
of any existing faults. 

Medical School Inspection. — School medical inspection service 
should accomplish two things: protect children from disease and 
determine their physical fitness. Physical defects should be remedied 
by the education of parents to the need of correction. Free vaccina- 
tion should be provided and dental prophylaxis taught. 

The accomplishment of these needs requires the services of phy- 
sicians, dentists and nurses. The medical school inspection service 
should, therefore, be studied for the program pursued and the personnel 
and size of the inspection force. In this latter connection, it may be 
stated that a minimum requirement is one physician for every three 
thousand pupils and one nurse for every fifteen hundred pupils. The 
teacher may also render valuable aid to the medical inspection service. 
She should be trained to recognize symptoms suggestive of communic- 
able disease and exclude each morning from class, pending the arrival 
of the medical inspector, any pupil whom she considers suspicious. 

The directive source of the inspection service should be determined. 
Most authorities consider that the health officer should be the directive 
head although it may work out when a part of the school system but 
cooperating with the health department. 



BOARD OF HEALTH LABORATORY 235 

Detailed studies should be made of the cases of communicable disease 
excluded from school, their isolation, supervision and release. The 
causes of physical defects in children should be determined, if possible, 
and preventive measures suggested. The adequacy of follow-up work 
of the nursing service with parents should be investigated. 

Charities. — Charities, public and private, may be a potential 
force in keeping the community on a healthy basis, because of the aid 
furnished the indigent sick. The first step is to consider the causes 
which are producing poverty in the community. Do they pertain to 
the individual, as alcoholism, drug addiction, venereal disease infection, 
gambling and idleness? Or may the causes be sought in the indivi- 
dual's environment? Thus we have the industrial environment with 
its exposure to industrial accidents and occupational diseases. Again, 
there is the home environment with possible exposure to disease, 
especially tuberculosis, through ignorance and carelessness. Possibly 
the child is set at work at an early age and a broken down body is 
sooner thrown out on the scrap heap of industry. The community 
may have an unusual number of indigent aged. The records of chari- 
table organizations should afford much light on the causes of poverty 
as well as the social state of applicants and thus point the way to 
remedial measures. 

What relief is furnished the dependent classes as the homeless, poor 
and dependent children, the destitute sick, the insane and weak minded? 
What public relief is given the poor in their homes? 

What is being done by the city? Does it provide free medical 
service in the form of a city physician? Are there free hospitals and 
dispensaries, free medicine and free nursing service? Does it maintain 
or contribute to the support of institutions for the indigent aged, the 
homeless poor, the dependent child or the insane and feebleminded? 
Are inmates of the various institutions afforded adequate care and 
attention? 

What are the private charitable organization of the city? How 
are they supported? Do they operate as single units or are they 
coordinated into a central power of force? Can applicants for relief 
appeal to several organizations or is a confidential bureau maintained 
to check this abuse. These conditions should all be studied and 
presented. 

Board of Health Laboratory. — The number of members, and ade- 
quacy of the laboratory force should be stated, for both the bacterio- 
logical and chemical divisions, with a brief statement as to their 
ability. Mention should be made of the laboratory equipment and its 
adequacy. 

Knowing the laboratory force and its equipment the extent to which 
it is used by the physicians of the community should be determined. 
Several reasons may cause physicians to disregard the laboratory. The 
older school men trained before the days of bacteriology may pin their 
faith on their ability as diagnosticians; while the younger men may have 
a microscope or laboratory of their own. The Board of Health may 



236 SANITARY SURVEYS 

not provide material in which specimens for examination may be 
collected, or if provided the method of their distribution may not be 
conveniently accessible to the busy physician. For the same reason 
it may be difficult for the physician to get the specimen to the Board 
of Health Laboratory and he prevails on the courtesy of the hospital 
laboratory while he is making his morning call at the institution. A 
study should be made of the number of yearly specimens examined by 
the laboratory and comparison made with the number of cases of 
disease reported to the Board of Health for the same period. In this 
manner some information may be secured on the use of the laboratory 
by physicians. The number of total examinations should be analyzed 
for the omission of any necessary test or tests or too few tests for a 
particular condition. 

Publicity and Education. — Many health departments are awaking 
to the value of educating the community in problems of public health 
and hygiene. Several methods have been utilized to this end as bulle- 
tins, cartoons, health almanacs, posters, press notices, lectures, popular 
talks, motion pictures, health exhibits, and intensive campaigns as a 
" Tuberculosis Day" or a "Baby Week." Forceful copy, in everyday 
language, used persistently in the daily papers is a strong medium, 
yet not extensively used. Any of the methods which have been em- 
ployed from time to time in the community should be carefully studied 
to see if the method "got across" and was successful in attaining its 
object. 

Mosquitoes Prevention and Control. — The breeding places of mos- 
quitoes should be carefully ascertained such as swamps, puddles, 
ditches, margins of ponds or other bodies of water, cesspools, cisterns, 
barrels, pails, street gutters, sewer catch basins, roof gutters, or in fact 
any receptacle where water may stand for ten days or more with warm 
atmospheric conditions. Ordinances relative to mosquito control 
should be given and existing methods of control as screening, draining, 
frequent oiling and premise inspections carefully studied. 

Fly Breeding. — Flies breed in decaying organic matters as stable 
manure or garbage. As most fly breeding is considered to occur in 
stable manure the first consideration is the number and construction 
of stables in the community. Particular attention should be paid to 
the stable floor, if of dirt, fly breeding is favored in the polluted soil. 
Receptacles for storing manure should be tight and dark. The stored 
manure should be collected preferably by the municipal authorities 
at weekly intervals. The method of disposal should be stated with 
observations as to its adequacy. Garbage cans should be water tight, 
covered and frequently collected for disposal. Ordinances relative to 
fly control should be given and mention made of any "fly campaign." 

Rat Eradication. — Rats are found in the wharfs along river fronts, 
in sewers, stables and markets, warehouses, garbage dumps, slaughter 
houses or any other place where food may be found. The principal 
methods of rat suppression may be considered as keeping them away 
from food, and the rat-proofing of buildings and wharfs. Ships tied 



HEALTH DEPARTMENT 237 

up at a dock, particularly ships from a foreign plague-infected port, 
should place metal guards on their hawsers. Buildings to be ratproof 
should have concrete footings, stout metal screens in basement windows, 
self-closing doors and water or drain-pipes protected by surrounding 
them with cement. Warehouse doors, or other establishments where 
food is found, should have a metal reenf orcement on the lower part of 
the door. Rat suppression methods will show some influence on other 
public health problems as cleaner dairy barns of better construction, 
prevention of fly breeding in stable floors, and cleaner better-kept back 
yards and areaways in the tenement house district. 

Health Department. — First consider the Board of Health itself. 
What is its size and composition? Standards will vary in different 
localities but a small board say of five members is neither too bulky or 
too small. Its composition in regard to the occupations of its mem- 
bers should be stated. As the Board acts in a judicial capacity for 
the community public health it should contain representatives from 
various professions which are associated with public health or its 
enforcement, as a physician, a sanitary engineer, a bacteriologist and 
a lawyer. The fifth member might be a representative business man. 
State the length of service of board members and by whom they are 
appointed. Inquiry should be made if the Board has full executive 
powers or is curtailed in some way. The ordinances under which the 
Board operates should be sufficient to inspect premises, collect speci- 
mens, examine individuals and quarantine or restrict their movements 
when necessary. The manner in which the ordinances are enforced 
should be stated as by order, abatement, or legal suit. The duties 
and powers of the health officer and his staff should be considered. 
The health department staff, may be divided into its component parts 
as food inspection, medical service and promotion of sanitation. Each 
department may then be studied for the number or members in its 
force, their duties and work accomplished during a current year. 
The health department office, or department of administration should 
be studied for the manner in which it keeps and files records. A very 
important division is the section on vital statistics. It should be well 
equipped, competently managed, and accurately depict the community 
death-rates. Compilation of records should be along standard lines as 
exemplified by International Causes of Death, and the rules of statis- 
tical practice adopted by the American Public Health Association. 
Classification of jointly reported death causes should be in accordance 
with the Federal Census Bureau's "Index of Joint Causes." Intercity 
comparisons of death-rates are difficult unless such standard and 
accepted methods are employed by the respective communities. 

The Health Department Budget. — The appropriation may be com- 
pared with similar appropriations for other municipal departments 
directed to the conservation or protection of life as the fire and police 
departments. The total appropriations should also be divided by the 
total population to bring it to a per capita basis. Various per capita 
figures have been suggested for health, ranging from fifty cents to one 



238 SANITARY SURVEYS 

dollar. The amount of money appropriated for the operation of the 
health department should be carefully studied for its adequacy. The 
criticism should he based on whether all the vital health problems 
are provided for in the budget or if important factors are omitted. 
For example a health budget could not be considered complete which 
made no provision for. a campaign directed to the reduction of in- 
fant mortality or tuberculosis. On the other hand the budget might 
place undue emphasis on a relatively unimportant health problem as 
plumbing inspection, or even on an item which might better be taken 
care of in some other city department as the collection of garbage. 
Statements have been made by several authorities on the relative 
importance of various public health problems and suggestions offered 
as to the amount of money required in the budget for each problem. 
Possibly no such definite standard can be set. If a community has 
a high foreign population high death-rates from certain diseases might 
be anticipated. Again, where there is a high negro population high 
death-rates for tuberculosis may be expected, or an industrial commu- 
nity with a large number of women at hard labor in its shops might 
have a high infant mortality-rate. The budget should be sufficiently 
elastic to meet the particular needs of the community. 






CHAPTER VII. 

AIR AND HEALTH— VENTILATION. 

By C. E. A. WINSLOW, Dr., P.H. 

THE RELATION OF ATMOSPHERIC CONDITIONS TO HEALTH 
AND EFFICIENCY. 

Bad Air and Good Air. — The evil effects of bad air conditions are 
obvious and clearly recognized. In a crowded, ill- ventilated room we 
experience a feeling of dulness, sleepiness, and under more extreme 
conditions perhaps nausea, and even faintness; and there are several 
classic instances in which conditions of the atmosphere have become so 
extreme as to result fatally. The most famous of these examples is 
the Black Hole of Calcutta, which Prof. Lee, of Columbia University, 
has described in the following sentences: 

"On one of the hottest of the hot nights of British India, a little 
more than one hundred and fifty years ago, Siraj-Uddaula, a youthful 
merciless ruler of Bengal, caused to be confined within a small cell 
in Fort William 146 Englishmen whom he had that day captured in a 
siege of the city of Calcutta. The room was large enough to house 
comfortably but two persons. Its heavy door was bolted; its walls 
were pierced by two windows barred with iron, through which little 
air could enter. The night slowly passed away, and with the advent 
of the morning death had come to all but a score of the luckless com- 
pany. A survivor has left an account of horrible happenings within the 
dungeon, of terrible strugglings of a steaming mass of sentient human 
bodies for the insufficient air. Within a few minutes after entrance 
every man was bathed in a wet perspiration and was searching for 
ways of escape from the stifling heat. Clothing was soon stripped off. 
Breathing became difficult. There were vain onslaughts on the windows; 
there were vain efforts to force the door. Thirst grew intolerable 
and there were ravings for the water which the guards passed in between 
the bars, not from feelings of mercy, but only to witness in ghoulish 
glee the added struggles for impossible relief. L T ngovernable confusion 
and turmoil and riot soon reigned. Men became delirious. If any 
found sufficient room to fall to the floor, it was only to fall to their 
death, for they were trampled upon, crushed, and buried beneath the 
fiercely desperate wave of frenzied humanity above. The strongest 
sought death, some by praying for the hastening of the end; some by 
heaping insults upon the guards to try to induce them to shoot. But 
all efforts for relief were in vain, until at last bodily and mental agony 
was followed by stupor. This tragedy of the Black Hole of Calcutta 
will ever remain as the most drastic demonstration in human history 
of the bondage of man to the air that surrounds him." 



240 AIR AXD HEALTH— VENTILATION 

Another famous example of the same phenomenon is described by 
Lewes. On Friday, December 2, 1848, the steamer "Londonderry" 
left Sligo for Liverpool with two hundred passengers on board, mostly 
emigrants. "Stormy weather came on, and the captain ordered every 
one to go below. The cabin for the steerage passengers was only 
18 feet long, 11 feet wide, and 7 feet high. Into this small place the 
passengers were crowded ; they would only have suffered inconvenience, 
if the hatches had been left open; but the captain ordered these to be 
closed, and — for some reason not explained — he ordered a tarpaulin 
to be thrown over the entrance to the cabin, and fastened down. The 
wretched passengers were now condemned to breathe over and over 
again the same air. This soon became intolerable. Then occurred 
a horrible scene of frenzy and violence, amid the groans of the expiring 
and the curses of the more robust : this was stopped only by one of the 
men contriving to force his way on deck, and to alarm the mate, who 
was called to a fearful spectacle : seventy-two were already dead, and 
many were dying ; their bodies were convulsed, the blood starting from 
their eyes, nostrils, and ears." 

The beneficial effects of good air are equally susceptible of demon- 
stration. Dr. Edward Trudeau went to Saranac in 1873 as a hopeless 
victim of consumption. All his friends were filled with horror at the 
idea of his going practically alone to die, as they believed, in the Adiron- 
dack wilderness, in a little town consisting of little more than a sawmill 
and half a dozen cabins, forty-two miles from a railroad. Dr. Trudeau 
did not die, however, during the winter of 1873, but grew very much 
better; and some ten years later, as a result of his experience, he 
founded the Adirondack Cottage Sanatorium, which in its primitive 
form consisted of a single house in which, with great difficulty, he 
persuaded two consumptive patients to live. That was the beginning 
of the demonstration in this country of the fresh-air treatment of 
tuberculosis, which Brehmer and others had introduced on the other 
side of the water. Today w r e are going through a reaction against the 
more extreme applications of very cold air, to sick people and to infants; 
but the general value of fresh air, if not too cold, and except in certain 
diseases, has been amply demonstrated. 

What are the factors to which these evil effects of bad air and these 
beneficial effects of good air are due? 

Composition of the Atmosphere. — The outdoor atmosphere in a 
state of normal purity is made up of the following gases, the volumes 
being measured at 0° C. and at 760 mm. pressure. 

Composition of the Atmosphere. 

Volumes, 
Gases. per cent. 

Nitrogen 78.09 

Oxygen 20. 94 1 

Argon 0.94 

Carbon dioxide 0.03 

Helium, krypton, neon, xenon, hydrogen, hydrogen peroxide, 

ammonia, nitric and nitrous acids traces 

1 0.01 may be in the form of ozone. 



ATMOSPHERIC CONDITIONS AND EFFICIENCY 241 

In crowded cities the proportion of oxygen in outdoor air may fall 
as low as 20.70 per cent, or even slightly less ; and the proportion of 
carbon dioxide may rise to 0.04 per cent, or more. 

In addition to these constituents the air always contains a certain 
amount of water vapor. Unlike the other gases present water vapor 
condenses at comparatively low temperatures and the amount of 
water which a given volume of air can hold is directly dependent on the 
temperature of the air. 

Amount of Water Vapor that can be Retained in Gaseous 
Form by Air at Different Temperatures. 

Temperature. . Water vapor. . 

Grams per Grams per 

°C °F cubic meter. cubic foot. 

-20 -4 0.887 0.39 

-10 14 2.139 0.94 1 

32 4.800 2.11 

10 50 9.280 4.08 

20 68 17.017 7.48 

30 86 29.871 13.13 



If, at a given temperature, the amount of water vapor in the air is 
increased beyond the saturation point the excess of moisture condenses 
out in the form of dew. Or if, with a given amount of moisture in the 
air, the temperature is lowered a point, called the dew-point, will 
ultimately be reached at which a similar condensation will take place. 
The amount of water vapor in the air at a given moment is generally 
expressed in relation to the total amount which it could hold if satur- 
ated. When the relative humidity of the air is said to be 75 per cent, 
we mean that that air contains three-quarters of the amount of water 
vapor that would saturate it at the existing temperature and pressure. 
The relative humidity of the air is perhaps its most variable quality 
at different places and different seasons. According to Macfie 1 the 
relative humidity in the heart of the Libyan desert may be as low as 
9 per cent, of saturation, while at Davos the mean relative humidity 
is 79 per cent. In California he states that the relative humidity may 
drop from 100 per cent, at dawn to 22 per cent, at noon. 

In addition to its gaseous constituents the air always contains a 
certain amount of finely divided solid matter in the form of dust par- 
ticles. If all particles, down to the very finest, are counted as may be 
done by the optical methods devised by Aitken the numbers found are 
enormous. They range from less than one per cubic centimeter on 
mountain tops (on exceptionally clear days) to hundreds of thousands 
or millions per cubic centimeter in ordinary indoor air. Considering 
only the particles of sensible weight and size (including diameters 
down to 0.0001 sq. mm.), recent analyses have shown the presence of 
.11 grams per million liters of air, or 900 dust particles per liter, in 
country air on a clear day. At the other extreme 760. grams per 

1 Air and Health, 1910, second edition. 
16 



242 AIR AND HEALTH— VENTILATION 

million liters, or 24,000,000 dust particles per liter, have been found 
in an abrasive factory. 

Bacteria are also present in ordinary air, but in small numbers, 
commonly varying from none to about ten per liter and rising to 
tens of thousands in very dusty air. 

Changes in the Composition of the Air as a Result of Human Occu- 
pancy. — Five different changes take place in this normal atmosphere 
when human beings occupy a confined space. 

1. The oxygen is reduced by respiration. Tiger stedt estimates the 
amount of oxygen absorbed by a man of average weight at rest as 764 
grams, or 534 liters per twenty-four hours. 

2. The carbon dioxide is increased by the same process. The oxygen 
consumption cited above, with a respiratory quotient of 0.80, would 
yield 840 grams, or 427 liters of C0 2 per twenty-four hours. 

3. There is given off into the air a greater or less amount of organic 
matter, which is perceived by us as odors — material given off not from 
the lungs to any extent but from the mouth, from the teeth, skin, and 
clothing. 

4. The temperature of the air is raised by the heat given off in the 
process of metabolism. The number of calories produced in twenty- 
four hours, corresponding to the oxygen consumption of 534 liters 
cited above, would be 2563.2 calories. About four-fifths of this, say 
2000 calories, is given off from the skin. Lusk and his associates have 
recently shown that the heat production bears a direct and close 
relation to the superficial area of the body and amounts for a resting 
individual to 953 calories in twenty-four hours per square meter of 
body surface (corresponding to an oxygen consumption of 198 liters 
per square meter of body surface). 

5. The humidity of the air is increased by the moisture given off 
in the breath and from the skin. The amount of moisture evaporated 
has been estimated as in the neighborhood of 1400 grams in twenty- 
four hours for. a man at rest. All of these values may be greatly 
increased by active exertion, and the amount of water given off, in 
particular, is radically altered by the heat and humidity of the sur- 
rounding atmosphere. 

Coincident changes in bacterial content and dust content (the 
latter influenced mainly by industrial processes) will be discussed in 
later sections. 

Physiological Effects of Changes in Oxygen and Carbon Dioxide. — In 
seeking, among the various changes noted above, for the cause of the 
physiological effects of vitiated air it was perhaps natural that the 
mind should turn to lack of oxygen as of prime importance. When a 
mouse is confined under a bell jar, it dies from oxygen starvation, and 
it was at first assumed that the same thing happens to a less degree 
in a badly ventilated room. As a matter of fact men do sometimes die 
from lack of oxygen in clogged sewer manholes (although poisoning 
by carbon monoxide is often at fault in such cases) or in the low parts 
of mines. 






ATMOSPHERIC CONDITIONS AND EFFICIENCY 243 

In such rooms as are ordinarily used for human occupancy, however, 
the changes in oxygen and carbon dioxide, even with the worst venti- 
lation, are found to be comparatively slight. The oxygen may fall from 
21 per cent, to 20 per cent., and the carbon dioxide may rise from 
0.03 to J per cent.; greater changes than these are not observed even in 
the most crowded and worst ventilated room on account of the leak- 
age through walls and ceiling and cracks of all sorts. Such values are 
very far from the values which are found to produce harmful physio- 
logical effects. The air in the lungs under normal conditions contains 
16 per cent, of oxygen and 5 per cent, of carbon dioxide and the respira- 
tory apparatus easily accommodates itself to considerable variations 
in the composition of the atmosphere by slight automatic changes in 
the rate and depth of respiration so as to maintain the composition 
of the alveolar air unchanged. In mines the oxgyen is often deliberately 
kept down to 17 per cent, or less in the hope of avoiding the dust 
explosions that are likely to follow in freely ventilated mines during 
cold weather. 

Some of the most interesting work along this line has been that in 
regard to the phenomena of mountain sickness. My colleague, Pro- 
fessor Yandell Henderson, with the English physiologists, Douglas 
and Haldane, 1 made a most important series of studies of this kind on 
Pike's Peak. On Pike's Peak the partial pressure of oxygen present 
corresponds to about 13 per cent, at ordinary atmospheric pressure. 
Under these conditions there are distinct symptoms of mountain sick- 
ness, as a result of oxygen deficiency, blueness of lips and face, loss of 
appetite, nausea and vomiting, intestinal disturbances, headache, 
fainting, periodic breathing, and great difficulty in getting breath on 
exertion. But even here, with the equivalent of only 13 per cent, of 
oxygen, after a few days the symptoms began to lessen, and after a 
few weeks of acclimatization the extreme conditions disappeared, 
although periodic breathing was still occasionally observed, and lips 
became blue on vigorous exertion. The investigators believed that at 
least three things had happened in this adaptation: In the first place 
the cells lining the alveoli of the lungs had acquired the power of 
secreting oxygen one way and carbon dioxide the other more vigorously 
for the same gaseous pressure than they would under ordinary con- 
ditions. In the second place the alkalinity of the blood had changed 
so as to stimulate the respiratory center with a less amount of carbon 
dioxide. And finally the hemoglobin had increased so as to supply the 
tissues more readily with the needed oxygen. 

Many people live active and vigorous lives under such conditions 
as this. In the great city of Potosi, in the Andes, for instance, the partial 
pressure of oxygen is very close to that at Pike's Peak, and many famous 
health resorts at an altitude of 5000 feet have a lower partial pressure 
of oxygen than obtains in the most crowded room. 

Nor have the ordinary changes in carbon dioxide content any greater 

1 Douglas, C. G., Haldane, J. S., Henderson, Y., and Schneider, E. C: Philosophical 
Transactions of the Royal Society of London, 1913, series B, cciii, 185. 



244 AIR AXD HEALTH— VENTILATION 

significance. For decades the carbon dioxide content of the air has been 
used as an index of its vitiation. Even in the standard text-book on 
Heating and Ventilation by Hoffman and Raber (published in 1910) 
one could read that "carbon dioxide is constantly being diffused through- 
out the air of the room, thus rendering it unfit for use. If this carbonic 
acid gas could be dissociated from the rest of the air and expelled from 
the room without taking large quantities of otherwise pure air with it, 
the problem of the heating engineer would be simplified, but this cannot 
be done." 

Yet Pettenkofer as long ago as 1863 showed clearly that carbon 
dioxide in itself is quite without effect in the highest concentrations 
which it ever attains in occupied rooms, and during the last fifteen 
years the researches of Fliigge, Haldane, Hill, Benedict and other 
physiologists have rendered the classic viewpoint wholly untenable. 
Benedict and Milner 1 observed seventeen different subjects kept for 
periods varying from two hours to thirteen days in a small chamber 
with a capacity of one hundred and eighty-nine cubic feet in which the 
air was changed only slowly while the temperature was kept down from 
outside. The amount of carbon dioxide was usually over thirty-five 
parts per 10,000 (or eight to nine times the normal) and during the day- 
time, when the subject was active, over one hundred parts, and at one 
time reached two hundred and forty parts; and all the "morbific 
matter" or other deleterious entities which usually accompany carbon 
dioxide must have been present in corresponding proportion. Yet 
there was no discomfort whatever, and no detectable disturbance of 
normal physiological functioning so long as the chamber was kept cool. 

In certain parts of breweries the carbon dioxide content is main- 
tained between \ and 2 per cent., without serious effects. The result 
of a concentration of 2 per cent, of carbon dioxide is simply an auto- 
matic 50 per cent, increase in depth of breathing such as occurs with 
moderate exercise. Only when such an excess of carbon dioxide is 
combined with vigorous exercise is discomfort experienced; and only 
when the concentration of C0 2 rises to 5 to 7 per cent, does dyspnea 
become distressing when the subject is at rest. At 10 to 11 per cent, 
headache, nausea and chilliness may occur. By observations on con- 
ditions in various industries, and at various altitudes, and by detailed 
physiological experiments of many observers, it has been shown quite 
conclusively that oxygen may fall as low as 17 per cent., and carbon 
dioxide may rise as high as 1 per cent, without harmful physiological 
effects. The body's respiratory "factor of safety" is a very high one, 
amply sufficient to take care of all variations in oxygen and carbon 
dioxide which are likely to occur. 

Effect of Organic Effluvia in the Air. — It is necessary, therefore, to 
seek for some other cause than changes in carbon dioxide and oxygen 
in order to account for the sensations experienced in badly ventilated 
rooms; and as the carbon dioxide hypothesis became untenable, hygien- 

1 Experiments on the Metabolism of Matter and Energy in the Human Body, U. S. 
Department of Agriculture, 1907, Bull. No. 175. 



ATMOSPHERIC CONDITIONS AND EFFICIENCY 245 

ists next turned to the possibility that poisonous organic substances 
might be given off from the human body. The obvious presence of 
" body odors" due to the decomposition of organic wastes in the mouth 
and on the skin and in the clothing gave a color of probability to such 
a hypothesis. This problem of "crowd poison," "anthropotoxin," 
" morbific matter" was a difficult one to study. It was simple enough 
actually to test the effect of various percentages of carbon dioxide and 
oxygen, but with organic matter of a hypothetical nature the oppor- 
tunity for mystic imaginings was almost unlimited. 

The conception of subtle organic poisons in the air is probably due to 
Brown-Sequard more than to any one else — Brown-Sequard, notable 
among biologists because he had three or four entirely erroneous 
opinions on important points which he supported by brilliant and 
apparently convincing experiments, and which it took decades to 
disprove. 

The putrefactive gases given off from fecal materials might be con- 
sidered as an extreme limiting case for the study of the effect of organic 
effluvia upon health. Even here, however, it seems doubtful whether 
any injurious influence can be shown. 

Delepine 1 could not detect any influence of sewer air either upon the 
growth curve of cats, rabbits and guinea-pigs or upon their suscep- 
tibility to a spontaneous epidemic due to infected food. David 
Greenberg repeated Alessi's experiments in the laboratory of the 
writer with entirely negative results (except for an initial slackening 
of growth which will be referred to later on). 

In a suggestive series of investigations conducted by Professor M. J. 
Rosenau, of Harvard, the attempt has been made to use the reaction 
of anaphylactic shock for the detection of very minute quantities of 
organic substances in the air. Professor Rosenau believed that he had 
demonstrated that there were such substances present in the expired 
air. He collected, for example, the matter expired in the breath of a 
dog and injected it into a guinea-pig, and later injected dog-blood 
serum into the guinea-pig, when the guinea-pig died with symptoms 
of anaphylactic shock, which would indicate that there was a specific 
protein substance given off in the breath, although of course not 
necessarily an intrinsically poisonous one. These experiments have 
now, however, been repeated by three other observers, by Leonard 
Hill in England and by Weismann and Lucas in New York City, the 
latter of whom worked under the direction of the writer. All three 
entirely failed to confirm Rosenau's experiments. 2 

Finally, some experiments carried out by the Xew York State Com- 

1 Report of the Sewer Ventilation Committee upon the Effects on Health of the Air 
of the High Street Sewer in Manchester, 1909. 

2 Rosenau, M. J., and Amoss, H. L.: Organic Matter in the Expired Breath, Jour. 
Med. Research, 1911, xxv, 35. Lucas, D. R.: An Investigation of Respired Air to 
Detect the Presence of Proteid Matter by the Anaphylactic Reaction, Report of Com- 
mittee on School Inquiry to the Board of Estimate and Apportionment, New York 
City, 1913, hi, 670. Weisman, C: Biochemical Studies of Expired Air in Relation 
to Ventilation, Dissertation submitted to Faculty of Pure Science of Columbia Univer- 
sity, 1913. 



246 AIR AND HEALTH— VENTILATION 

mission on Ventilation reopen this question in a somewhat different 
form. In the course of these experiments subjects kept in an experi- 
mental chamber under controlled atmospheric conditions were served 
with a standard luncheon, and the amount that they left on the plates 
was afterward weighed so as to see how much they had eaten. We gave 
our subjects on certain days fresh outside pure air, on other days we 
kept the same air in the room all day, allowing it to become chemically 
vitiated but regulating its temperature. We found, somewhat to our 
surprise, that comparing the fresh-air and vitiated-air days with the 
same temperature and humidity there was a distinct difference in the 
amount of food eaten. The four series which were completed showed 
uniformly an excess of food eaten on fresh-air days, the excesses in 
the four series amounting to 4.4, 6.8, 8.6, and 13.6 per cent., respectively. 
There were from 71 to 160 meals served in each series; and the results 
are distinctly suggestive of a psychological effect or reflex reaction 
to the body odor which may apparently exert a measurable effect 
on appetite. 1 David Greenberg and the writer have been conducting 
experiments at the Yale Medical School which appear to offer con- 
firmatory evidence along this line. In these studies guinea-pigs 
exposed to the odors of decomposing feces showed a less rapid growth 
curve than normal animals for the first few days of exposure. The 
effect was entirely transitory, however, the animals exposed to the 
putrid gases soon catching up completely with their controls. 

Physiological Effects of Temperature and Humidity. — It was 
Hermann who in 1883 first pointed out that heat and moisture were 
probably the factors that produced the harmful effects of bad air 
rather than its chemical composition, but most of the fundamental 
work on the subject was done in 1905 or thereabouts by Fliigge and 
his pupils. These experiments have been repeated by Hill and Haldane 
in England, and by Benedict and others in this country, and all of the 
results have tended to show that Hermann was correct. 2 

In these experiments the subjects when placed in carefully con- 
trolled closed chambers experienced the symptoms that one is accus- 
tomed to associate with badly ventilated rooms. If they were allowed 
to breathe outside air through a tube they were not relieved. If 
subjects outside were allowed to breathe the vitiated air through a 
tube, they did not experience discomfort. These two simple experi- 
ments appear to be entirely conclusive as to subjective symptoms. 
The feeling of uncomfortableness affected the men in the chamber, 
not the men outside the chamber, whatever air each group was breath- 

1 Winslow, C.-E. A., and Palmer, G. T.: The Effect upon Appetite of the Chemical 
Constituents of the Air of Occupied Rooms, Proceedings, Soc. Exper. Biol, and Med., 
1915, xii, 141. 

2 Fliigge, C: Ueber Luft Verunreinigung, Warmestauung, und Liiftung in geschlos- 
senen Raumen, Ztschr. f. Hyg. u. Inf., 1905, xlix, 363. Henderson, Y. : The Unknown 
Far-tors in the 111 Effects of Bad Ventilation, Trans. Fifteenth Inter. Cong, on Hyg. and 
Demog., Washington, 1913, ii, 622. Hill, L., and Flack, M., Mcintosh, J., Rowlands, 
R. A., and Walker, H. B.: The Influence of the Atmosphere on Our Health and Com- 
fort in Confined and Crowded Spaces, Smithsonian Miscellaneous Collections, 1913, 
No. 23, vol. lx, Smithsonian Institution, Washington. 



ATMOSPHERIC CONDITIONS AND EFFICIENCY 247 

ing. It was the heat and moisture produced by their bodies which 
caused the feeling of discomfort, by its effect not on the lungs but on 
the skin. 

Leonard Hill comments on his experiments in England as follows : 

"In one class of experiments we shut within the chamber seven or 
eight students for about half an hour and observed the effect of the 
confined atmosphere upon them. We kept them therein until the C0 2 
reached 3 to 4 per cent., and the oxygen had fallen from 17 to 16 
per cent. The wet-bulb temperature rose meanwhile to about 80° to 
85° F., and the dry-bulb a degree or two higher. The students went in 
chatting and laughing, and by and by as the temperature rose they 
ceased to talk and their faces became flushed and moist. We have 
watched them trying to light a cigarette (to relieve the monotony of 
the experiment) and puzzled by their matches going out, borrowing 
others, only in vain. They had not sensed the percentage of the 
diminution of oxygen, which fell below 17. Their breathing was slightly 
deepened by the high percentage of C0 2 , but no headache occurred in 
any of them from the short exposure to from 3 to 4 per cent. C0 2 . 
Their discomfort was relieved to an astonishing extent by putting on 
the electric fans placed in the roof. While the air was kept stirred 
the students were not affected by the oppressive atmosphere. They 
begged for the fans to be put on when they were cut off. The same 
old stale air containing 3 to 4 per cent. C0 2 and 16 to 17 per cent. 2 
was whirled, but the movement of the air gave complete relief, because 
the air was 80° to 85° F. (wet bulb), while the air enmeshed in their 
clothes in contact with their skin was 98° to 99° F. (wet bulb). The 
whirling away of this stationary air cooled the body effectually, for 
air at 80° to 85° F. holds considerably more water vapor when heated 
up to from 98° to 99° F." 

Such experiments as these have demonstrated quite conclusively 
that the cause of the ordinary sensations of discomfort experienced in a 
badly ventilated room are, as Professor Lee has expressed it, " physical 
not chemical; cutaneous, not respiratory." 

The regulation of body temperature among the higher mammals and 
birds is accomplished in part by modification of heat production, 
in some small part by varying heat loss and evaporation from the 
respiratory mucous membranes, and in the main by varying heat 
loss and evaporation from the external skin. Changes in heat pro- 
duction are accomplished through increased or decreased muscular 
activity, and increase in heat loss at high temperatures is facilitated 
by panting, though this is only important in animals which do not 
perspire freely. In man heat loss is regulated almost exclusively by 
changes in the dilation of the bloodvessels of the skin and by the 
varying activity of the sweat glands — operating under the control of 
the heat center in the corpus striatum. 

In view of the importance of evaporation as a factor in the regulation 
of heat loss, humidity must always be considered as well as temperature 
in judging of the effect of any given atmospheric condition upon the 



248 AIR AND HEALTH— VENTILATION 

body. Ilaldane, the English authority upon this branch of physiology, 
maintains that "it is the temperature indicated by the wet-bulb 
thermometer (not the actual air temperature as shown by the dry-bulb 
thermometer, nor the amount of moisture in the air, nor the relative 
humidity) which determines the ill effects produced." (See page 286.) 
A third condition, air movement, is an equally important factor in the 
problem, since in a still atmosphere the body is covered by a layer 
of hot moist air which exerts upon it a direct influence far more detri- 
mental than that of the surrounding atmosphere in general. The com- 
bined cooling effect of all three factors can be measured by Leonard 
Hill's Katathermometer (see page 288). Studies made with this 
instrument show that a temperature of 26° C. outdoors with a moderate 
breeze blowing may be more cooling in its effect and hence more com- 
fortable than a temperature of 22° indoors. This is the reason why 
an overheated room in winter (the air being still) is so much more 
uncomfortable than a hotter day outdoors in summer (when the air is 
generally more or less actively in motion). 

Striking evidence in regard to the effect of high temperature com- 
bined with high humidity was accumulated in connection with the 
work of the English Departmental Committee on Humidity and 
Ventilation in Cotton Weaving Sheds (1909, 1911). Experts testified 
in this inquiry that the workers in mines subjected to a high wet-bulb 
temperature exhibit a marked degree of lassitude and exhaustion. 
According to Professor Cadman exertion begins to be accompanied 
with depression from a wet-bulb temperature of about 25° C. At 
27.8° wet bulb "if clothes be removed and maximum body surface 
exposed work can be done providing a current of air is available." At 
29.4° "only light work is possible," and at 35° work becomes out of 
the question. 

Haldane in the same inquiry says that soldiers marching in uniform 
are liable to heat stroke at wet-bulb temperatures of under 21° C; 
that at 26.7° wet bulb a marked rise of body temperature is noted with 
muscular exercise, and hard and continuous work is impracticable 
even when the subject is stripped to the waist; while at 31°-32° wet 
bulb " in fairly still air the body temperature begins to rise, even in the 
case of persons stripped to the waist and doing no work; and when 
once started this rise continues until symptoms of heat stroke arise, 
unless the person leaves the warm air." 

The ultimate effects of overheating when carried to its physiological 
limit have been well described by Charles N. Fiske, 1 Surgeon in the 
United States Navy. Temperatures in the furnace rooms of naval 
vessels in the Tropics in early days sometimes passed 65° C. dry bulb 
and in one case reached 96° with a high humidity. In 1909 and 1910 
the attack rate for heat stroke in the Navy was about 8 per 1000 and 
between 1801 and 1911 there were twenty deaths and thirty-three men 
invalided from this cause. Severe -cramps and muscle twitchings 

1 Am. Jour. Med. 8c., 1913, cxlv, 565. 



ATMOSPHERIC CONDITIONS AND EFFICIENCY 249 

attributed to local dehydration of tissues and accumulation of kata- 
bolic products in excess are among the pronounced symptoms of heat 
stroke, and the body temperature regulation may be completely upset 
so that a fever temperature of 40° to 47° may be recorded. The 
symptomatology and pathology of this disease strongly suggest an 
auto-intoxication due to metabolic products and a striking analogy 
has been suggested with the phenomena of fatigue. 

In the practical study of ventilation we are less concerned with such 
extreme influences of very high temperatures than with the slower and 
more subtle effects of less excessive temperatures; and in this latter 
field the extensive investigations of the New York State Commission 
on Ventilation have thrown some new light upon the general problem. 

These experiments dealt with the effect upon a large number of sub- 
jects of three atmospheric conditions: 20° C. with 50 per cent, relative 
humidity (13° wet bulb) ; 24° C, with 50 per cent, relative humidity (16° 
wet bulb) ; and 30° C. with 80 per cent, relative humidity (27° wet bulb). 
At 24° dry bulb the average rectal body temperature of the subjects 
was 2 per cent, higher and at 30° it was 5 per cent, higher than at 20°, 
showing that the homoiothermy of the human body is after all only 
relative and not absolute, even within a moderate range of atmos- 
pheric temperature. A somewmat surprising observation was the close 
relation between the rectal body temperature at 9 a.m. and the mean 
air temperature for the twelve hours preceding. The curves were so 
perfectly parallel as to leave no reasonable doubt of the direct relation 
of cause and effect. There have been conflicting results reported by 
various observers who have compared body temperatures in the 
Tropics and in the Temperate Zone; and it may be that after a pro- 
longed sojourn in a warm climate a compensating mechanism is 
developed which maintains a lower body temperature with a given 
atmosphere outside. 

In addition to this direct effect upon the body temperature, atmos- 
pheric heat exerts a somewhat profound influence upon the general 
status of the vasomotor machinery. It was shown in the New York 
experiments that the reclining pulse-rate was on the average 5 beats 
higher and the standing pulse-rate 12 beats higher at 24° — the reclining 
pulse-rate 8 beats higher and the standing pulse-rate 17 beats higher 
at 30° — than at 20°. The systolic blood-pressure was not affected 
at 24° but was decreased by 2 mm. reclining, and by 7 mm., standing, 
at 30°. The diastolic blood-pressure, reclining, was 5 mm. lower at 
24° and 10 mm. lower at 30°, while the average for the standing position 
was the same at 20° and 24° but was lowered by 7 mm. at 30°. The 
Crampton value, an arbitrary index of the general tone of the vasomotor 
system, obtained from the relation, between the changes in blood- 
pressure and heart-rate on passing from a reclining to a standing 
posture, was 58 at 20°, 53 at 24°, and 36 at 30°, indicating a progres- 
sively less efficient condition of the vasomotor mechanism with 
increasing atmospheric temperature. 

In other words an overheated room — even a moderately overheated 



260 



AIR AND HEALTH— VENTILATION 



room (24° C. or 75° F.) — produces profound effects upon the circulatory 
and vasomotor systems of the body, including an increase in body 
temperature and heart rate and a lowering of the Crampton and other 
indices which measure the facility of adaptive reaction of the vascular 
system. No other physiological effects than these could be demon- 
strated even at the extreme condition of 30° C. (86° F.), with 80 per 
cent, relative humidity; respiratory rate, dead space in the lungs, 
acidity of the blood, respiratory quotient, rate of heat production, 
rate of digestion, protein metabolism, concentration of the urine and 
skin sensitivity being all studied in the New York experiments. Stag- 
nant air at the same temperature as fresh air, even when it contained 




Fig. 23. — View of experimental chamber, New York State Commission on Ventilation. 
One subject at the left is having blood-pressure reading taken, while the other three are 
typewriting under the direction of the psychologist. 

2 per cent, or more of carbon dioxide and all the organic and other 
substances present in the air of an unventilated room, had no measur- 
able effect on any of the responses studied, aside from the influence on 
appetite discussed above. 

Effect of Atmospheric Temperature and Humidity upon Efficiency. — 
The most significant results of the New York State Commission study 
are probably those which bear on the effect of high atmospheric tem- 
peratures upon the working power — or more properly, the actual 
performance of the working organism. The statement must be limited 
in this way because the actual power to do either mental or physical 
work, for a short period, and under a strong stimulus, was not dimin- 
ished, under the conditions of our experiments, even by the extreme 



ATMOSPHERIC CONDITIONS AND EFFICIENCY 



251 



condition of 30° temperature with 80 per cent, relative humidity. The 
observations of Cadman and Haldane, cited above, make it probable 
that very heavy or prolonged work would have been really impossible 
under these atmospheric conditions but we did not reach this limit. 
Short of the point where marked pathological changes set in, it is a 
matter of common experience that even a highly uncomfortable degree 
of heat is no hindrance to absorbing intellectual work and no bar to 
a good game of tennis. 



Si 




1 


jS» 37.QP 
t§k& 3650 

a 

a* ° 

££ 4 
6 

111 " 6 

Ml 50 

30 
IOO 

K so 








Body Tcmpcbature 














^ ^ 




^ "^^DlFFERENCE IN 

Pulse-Rate-,'ncrease - 




at Beginning and End of Period 










Blood Pressure 


— ^__ 














Cramp-ton Vauje"^ — 












^"-^^^ 




work Done 








< 


58 15 66 
?oom Temperature, Fahr 





Fig. 24. — Effect of room temperature upon body temperature, pulse-rate, blood-pressure, 
Crampton value and efficiency. (New York State Commission on Ventilation.) 

The effect actually noted in the New York Commission studies was 
of a somewhat different kind and was brought out by a series of 
"option tests" in which the subjects were not forced to work at all but, 
during a given period, were given a choice between physical or mental 
work on the one hand and idling on the other. If they did perform the 
work they were paid a small cash bonus, so adjusted as to offer a slight, 
but only a slight, incentive — a condition approximating the ordinary 
conditions of school and industrial life (where payment is not on a piece 
work basis), in furnishing a real but not an overmastering stimulus to 
effort. 

Even this form of option test did not disclose any inhibiting effect 
of the 24° condition on purely intellectual work such as mental multi- 



252 AIR AXD HEALTH— VENTILATION 

plication. On the contrary, the average of three series of tests with 
47 different subjects, extending over a period of sixteen weeks, showed 

that 4.9 per cent, more mental multiplication was done at 24° than at 
20°. It may he that work of this kind offered a certain mental dis- 
traction under slightly uncomfortable conditions; or it is possible 
that the subjects found the 20° condition somewhat too cool for purely 

tentary work. At 30° we found a distinctly unfavorable effect even 
upon mental multiplication. 

Typewriting, which involves a certain amount of muscular exertion 
and hence an increase of internal heat production) was clearly affected, 
in all our experiments, by even a slight increase in atmospheric tem- 
perature. The average amount of typewriting done under the con- 
ditions of the option tests was 6.3 per cent, greater at 20° than at 24". 
With heavier physical work, such as lifting dumb-bells or riding a 
stationary bicycle, the influence of high temperature was still more 
marked. Tests made on the same optional basis showed that 15 per 
cent, more work was done at 20° than at 24° and 37 per cent, more at 
20° than at 30 . 1 

These experiments indicate that in the daily life of the school and 

I the factory overheating of the air must exert serious effects upon both 

efficiency and health. Their results are in general in striking accord 
with the brilliant investigations of Professor Ellsworth Huntington of 
Yale University, as presented in his book entitled Civilization and 
Climate. Professor Huntington studied the effect of season upon 
mental and physical work — physical work of operatives in various 
industrial communities from Connecticut to Florida, and mental work 
of students at West Point and Annapolis. He showed that there was 
a distinct falling off in the amount of work when the mean outdoor 
temperatures went above <oo° to 70° F. He found that there was a 
still more marked decrease when the temperature fell below 40° to 
F. There was a period of maximum productivity in both factories 
and educational institutions in spring and fall, with a minimum period 
in winter and another minimimi in summer. The most favorable 
mean outdoor temperature for the twenty-four hours was about 60.° 
Moderate changes, on the other hand, in either direction were stimu- 
lating. In Professor Huntington's book he connects these observations 
in a most interesting and suggestive way with the efficiency of mankind 
under the various climates of the globe. 

It is possible that these inhibiting effects of increased atmospheric 
temperature upon the tendency to physical work may be due to 
ti>sue intoxications of the same kind as those probably concerned 
in the incipient stages of heat stroke recorded by Cadman and Haldane, 
differing from them only in degree. They may also, however, be ex- 
plained as due simply to an abnormal distribution of the blood supply, 
and particularly to the relative anemia of nerve and muscle tissue 

1 New York State Commission on Ventilation: Some Results of the First Year's 
rk of the New York State Commission on Ventilation, Am. Jour. Pub. Health, 1915, 
v, 85. 



ATMOSPHERIC CONDITIONS AND EFFICIENCY 253 

which may be assumed to accompany marked dilatation of the periph- 
eral vessels. The fact that a strong stimulus to activity can over- 
come the inertia involved seems to point in this direction. If this 
hypothesis be correct the disinclination to do active work at a moder- 
ately high atmospheric temperature may indeed be interpreted as a 
protective reaction designed to guard the body from the evil effect 
which may follow an energetic heat production under conditions 
which make heat dissipation difficult. 

Effect of Atmospheric Temperature upon Resistance to Disease. — 
Whatever the mechanism of the action may be it is clear that varying 
atmospheric temperatures exert a profound influence upon the organ- 
ism as a whole. We might naturally expect that the resistance to 
microbic infections and other diseases would also be materially affected 
by unfavorable atmospheric conditions; and experience shows that 
such is indeed the case. 

The most striking direct evidence in regard to the harmful effect 
of high atmospheric temperatures is that furnished by the effect of 
season upon infant mortality. It might be supposed that the infant, 
having more surface to get rid of the heat in comparison with its bulk, 
would not suffer severely from heat, but this advantage is much more 
than overbalanced by. the greater sensitiveness of its organization. 
The combined effect of artificial feeding and high atmospheric tem- 
perature is what causes the great loss of infant life from summer com- 
plaint. A young baby can usually live in cold weather even when fed 
with poor cow's milk; a baby can live through severe summer weather 
if it is fed at the breast or on modified pasteurized cow's milk. The 
combination is the deadly thing. 

The effect of atmospheric temperature upon respiratory disease is 
particularly direct and important. The studies of Hill and Muecke 
in England and the experiments of the New York State Commission on 
Ventilation in this country 1 have shown that in going from a hot room 
to a cold room the membranes of the nose become paler and less moist, 
while the inferior turbinates contract. With a sharp and sudden 
change, however, such as occurs when the subject passes from a hot 
room into a cold room with a strong draft on the face, it frequently 
happens that while the redness of the membranes decreases, the 
swelling and paleness do not decrease but often increase, so that the 
membranes are swollen and bathed with mucous secretion, but without 
an ample blood supply — an ideal condition for the cultivation of 
disease bacteria. Apparently this is the phenomenon which lies at 
the base of "catching cold" by going from a hot room into the cold air. 

In the New York studies a number of workers were examined who 
had lived under abnormal conditions— furnace men, exposed to hot, 
dry air; laundrymen, exposed to hot, moist air; and truckmen and 
teamsters, exposed to severe outdoor-air conditions. Abnormal 

1 Hill, L., and Muecke, F. F.: Colds in the Head, Lancet, 1913, clxxxiv, 1291. 
Miller, J. A., and Cocks, G. H.: The Effect of Changes in Atmospheric Conditions 
upon the Upper Respiratory Tract, Tr. Am. Climatol. and Clin. Assn., 1915. 



254 



AIR AND HEALTH— VENTILATION 



reactions were found among these subjects in much greater degree; 
and these occupational groups showed much more chronic nasal 
disease than did normal subjects. About 3 per cent, of normal subjects 
(students) had chronic diseases of the nasal passages, 19 per cent, of 
the outdoor workers, 35 per cent, of the furnace men, and 46 per cent. 
of the laundrymen. Both the experimental work and this statistical 
work on the various occupational groups pointed to the very serious 
effects of hot air upon the mucous membranes, and particularly the 
danger of passing from such a condition into chill outdoor air. 

Animal experiments have clearly indicated that exposure to sudden 
chill exerts a definite predisposing influence toward respiratory 
infections. 1 

Striking evidence of the effect of relatively slight variations in 
atmospheric conditions upon the incidence of disease is offered by a 
study of respiratory disease among school children conducted by Dr. 
S. Josephine Baker 2 of the New York City Department of Health in 
cooperation with the New York State Commission on Ventilation. 
This investigation covered two periods of about four months each 
during the winters of 1916 and 1917, between 2500 and 3000 children 
being under observation for each period. The 58 classrooms studied 
in 1916 and the 76 classrooms studied in 1916-1917 were primarily 
divided into three groups according to the method of ventilation used. 
The results will be discussed from this standpoint in a later section. 
A classification of the data according to the temperature maintained 
in the rooms is most significant from our present standpoint. 

Relation Between Schoolroom Temperatures and Respiratory 

Diseases. 





Group 

of 
rooms. 


Average 
tempera- 
ture, F. 


Percentage of sessions. 


Respiratory disease, 

rate per 1000 pupil 

session. 


Year. 


Below 60°. 


60° to 69°. 


Above 69°. 


Absences 

due to 

respiratory 

disease. 


Respiratory 
diseases 
among 
pupils in 

attendance. 




1 


59.1 


52 


46 


2 


10.4 


42.6 


1916 | 


2 


66.6 


4 


78 


18 


8.2 


58.0 




3 


69.8 





40 


60 


15.8 


68.0 


f 


! 


59.6 


42 


56 


2 


10.1 


69.3 


1916-17J 


2 


66.6 


2 


97 


1 


9.3 


39.5 


3 


69.1 





95 


4 


15.4 


103.7 



Respiratory diseases among pupils in attendance were least prevalent 
during the first year in the coldest group of rooms, but absences due 

1 Miller, J. A., and Noble, W. C: The Effects of Exposure to Cold upon Experi- 
mental Infection of the Respiratory Tract, Jour. Exper. Med., 1916, xxiv, 223. 

2 Classroom Ventilation and Respiratory Disease among School Children, Am. Jour, 
Pub. Health, 1918, viii, 19. 



ATMOSPHERIC CONDITIONS AND EFFICIENCY 255 

to respiratory disease in this year and both absences and cases of 
respiratory disease among pupils in attendance during the second year 
were least in the rooms averaging 66.6° F. In every instance the 
warmer rooms (although they only averaged between 2° and 3° higher 
than the middle class) showed a very materially higher respiratory 
disease rate than either of the other groups. Other factors than mean 
temperature that may have entered into these results will be discussed 
below. 

The most striking demonstration of the influence of atmospheric 
conditions upon human vitality is an exhaustive statistical study of 
the monthly variations in temperature, humidity and death-rates in 
different parts of the world by Ellsworth Huntington. Professor 
Huntington shows by an ingenious method of analysis of millions of 
deaths in widely separated regions that the minimum death-rate occurs 
with a mean twenty-four-hour temperature of 64° and a mean twenty- 
four-hour relative humidity of 80 per cent, of saturation, deviations in 
either direction being followed by an increasing mortality. Moderate 
variations about this mean are, however, apparently beneficial and 
populations exposed for long periods to very uniform climates such as 
that of California show a markedly increased susceptibility to unfavor- 
ably high or low temperatures when they do occur. 

Physiological Effects of Atmospheric Humidity. — It is well estab- 
lished that high atmospheric humidity combined with high atmospheric 
temperature is exceedingly deleterious in its effect on the human organ- 
ism. This is of course an indirect temperature effect, since at high 
temperatures the body depends mainly on evaporation to maintain its 
necessary heat loss and the presence of atmospheric moisture interferes 
with such evaporation. At very low temperatures high humidity 
is also harmful since under such conditions the body loses heat mainly 
by conduction and convection and the moisture deposited in the 
clothing from a damp atmosphere tends to increase conduction. Thus 
excessive moisture makes hot air feel hotter and cold air feel colder. 

Within the ordinary ranges of room temperature the evaporation 
effect is the one chiefly to be considered, and inside these ranges, a 
higher degree of humidity is preferred the lower the temperature falls. 
The Comfort Zone worked out by Ellen H. Richards gives a fairly 
good view of the way in which sensations of satisfaction vary with 
changing atmospheric humidities and temperatures (see Fig. 25). 

Aside from these effects of atmospheric humidity upon the tem- 
perature exchanges of the body it has been believed by many hygienists 
that a reduction of humidity below the normal had a direct and specific 
harmful influence of another kind. It has been claimed that very dry 
air was an important predisposing cause of respiratory disease, and that 
it was conducive to nervousness and general bodily discomfort. 

In considering the influence of dryness, as in the case of temperature, 
we must take the factor of air movement into account. There has been 
much loose talk about school rooms "drier than the Desert of Sahara;'' 
and it is true that the air of heated school rooms in cold climates 



256 



AIR AND HEALTH— VENTILATION 



doos often show as low a relative humidity as desert air. G. T. Palmer 
has recently shown, however, that the actual drying effect, as measured 
by the water evaporated from a porous cup under standard conditions, 
is much less in the school room than in the desert on account of the 
relatively slight air movement. 






10 


20 


The Curve of 

30 40 50 


Comfort 

60 70 


80 


90 


100 


















R< 


5lat 


ve] 


lun 


lidii 


y 


















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Fig. 25. 



-Relation between the sensation of comfort and temperature and relative 
humidity. (Richards.) 



Such experimental results as are available in regard to the supposed 
harmful effect of dry air per se are almost wholly negative. The New 
York State Commission on Ventilation devoted a considerable amount 
of time to researches along this line. Direct observations of the effect 
of various atmospheric conditions upon the nose and throat showed 
that hot moist air was worse than hot dry air, and this conclusion was 
borne out by the fact that laundrymen, exposed to hot, moist air 
showed a higher percentage of atrophic rhinitis than furnace men 
exposed to hot, dry air. In regard to the question of nervousness 
induced by dry air, the Commission undertook extensive investigation 
of the psychological reactions of experimental subjects and the health 
and intellectual progress of school children exposed to air of varying 
degrees of dryness; but no effect of the dry air could be detected by 
the methods used. It should be noted that the variations in relative 



ATMOSPHERIC CONDITIONS AND EFFICIENCY 257 

humidity studied were not very great, ranging only between 20 and 50 
per cent, of saturation in the cabinet experiments and between 29 and 
42 per cent, in the school rooms, for it is not practicable to humidify 
school room air to any great extent in cold weather without producing 
frosting on windows. 

The statistical studies of Professor Huntington which have been 
discussed above indicate, on the other hand, that reduced atmospheric 
moisture is distinctly harmful as measured by the effect of climatic 
variations upon the death-rate. The most favorable mean relative 
humidity for the twenty-four hours as indicated by his graphs is 80 
per cent, of saturation, which would perhaps correspond to a midday 
humidity of 60 to 65 per cent. It may be that the brief period of the 
New York experiments and the relatively small number of subjects 
was insufficient to reveal detrimental effects which were really present. 
On the other hand it is equally possible that the comparatively slight 
variations in humidity which it is possible to obtain by artificial 
humidification when operating for the short period of the school session, 
do not really exercise such influences as are manifested by climatic 
variations extending over the whole twenty-four hours. The effect of 
dryness when studied by the statistical method may also perhaps be 
complicated by other factors such as variability and wind movement. 

Bacterial Pollution of the Atmosphere. — In the early days of sanitary 
science the atmosphere was supposed to play a large part in the spread 
of disease; but more recent observations have made it clear that the 
danger of the aerial transmission of bacteria was exaggerated. 

Two principal ways have been suggested in which bacteria might 
be transported through the air — in the form of dust and in the form of 
mouth-spray. Cornet and many other investigators have dwelt upon 
the danger of infected dust, particularly in the case of tuberculosis. 
The dust which collects in streets and on floors and other surfaces 
indoors is indeed rich in microbic life. Winslow and Kligler 1 report 
an average of 49,200,000 microbes per gram in Xew York street dust 
and between 3 and 5 millions per gram in indoor dust. The flora of 
the street dust included an average of 51,000 colon bacilli and 42,500 
acid-forming streptococci. The results of earlier investigators indicate 
that the tubercle bacillus may sometimes be found in 5 to 10 per cent, 
of samples of dust not specially exposed to tuberculous infection, while 
in the neighborhood of phthisical patients 25 to 50 per cent, of such 
tests may prove positive. Quantitative determinations suggest that 
under these conditions Bacillus tuberculosis may be present in numbers 
ranging from 5 to 20 per gram of dust. 

It should be emphasized, however, that the dust examined in these 
investigations was lying inert on floors and other surfaces and could 
only be distributed in the air by more or less violent agitation. Such 
distribution does not ordinarily occur. When dust is violently stirred 
up by dry sweeping or beating carpets indoors or still more by a March 

1 A Quantitative Study of the Bacteria in City Dust with Special Reference to Intes- 
tinal and Buccal Forms, Am. Jour. Pub. Health, 1912, ii, 663. 
17 



Microbes per cubic foot. 


Acid-forming 






streptococci per 






20° 


37° 


100 cubic feet. 


56 


30 


12 


72 


32 


11 


94 


80 


22 


96 




30 


113 


63 


43 



258 AIR AND HEALTH— VENTILATION 

wind in a poorly cared-for street we have, however, another set of con- 
ditions. Under such circumstances we take considerable quantities 
of dust into the nose and throat, and inhaling large quantities of dust 
may have a real sanitary significance. 

The importance of the mouth spray as a disseminator of disease 
germs was first emphasized by Fliigge. It is now well recognized that 
in coughing, sneezing and loud speaking droplets are thrown out which 
may contain great numbers of mouth bacteria. Quantitative experi- 
ments have shown, however, that the mouth spray is not a floating 
mist but a fairly coarse rain which quickly settles out of the air and 
does not produce any important aerial contamination except in the 
immediate vicinity of the individual producing it. The mouth spray 
is an important agent in the spread of disease germs, but it is really a 
form of contact infection rather than a problem of general atmospheric 
pollution. In the diseases caused by filterable viruses, such as smallpox 
measles, and infant paralysis, which are characterized by a very high 
degree of communicability, it is possible that the mouth spray is even 
more important than in other diseases. 

That both dust and mouth spray are local rather than widespread 
atmospheric pollutions is indicated by the results of bacteriological 
examinations of air which show numbers so low as to make it clear that 
a general pollution by either dust or mouth spray must be rare. Basker- 
ville and Browne and the writer 1 have reported, for example, the results 
of the examination of 1037 samples of air with the average results 
indicated below. The counts on individual samples varied from to 
5200 per cubic foot. 

Average Microbic Content of Air from Various Sources. 

Source of Number 

samples. of samples. 

Outdoors — country . . 85 
Outdoors — city . . .134 

Offices 87 94 80 22 

Schools 684 96 . . 30 

Factories 47 113 63 43 

The fact that the acid-forming streptococci which offer a fair index 
of pollution with mouth-spray are from two to four times as abundant 
in indoor as in outdoor air is significant of a real, though slight degree 
of aerial pollution. The relative importance of danger from such 
diffused pollution must, however, be slight in comparison with the mass 
infection which occurs in the spread of disease by contact or by exposure 
to direct and immediate pollution of concentrated mouth-spray. 

The principal factor in promoting bacterial infection by means of the 
mouth-spray is overcrowding rather than poor ventilation, the two 
conditions being often but not always necessarily correlated. There 
can be no doubt that jamming of human beings in street cars or 

1 Winslow, C.-E. A., and Brown, W. W.: The Microbic Content of Indoor and 
Outdoor Air, Monthly Weather Rev., 1914, xlii, 452, 



ATMOSPHERIC CONDITIONS AND EFFICIENCY 259 

barracks is harmful but the danger can be removed only by relieving 
congestion. Excessive air movement would aggravate rather than 
mitigate the evil. 

The Harmful Effect of Atmospheric Dust and Fumes.— The breath- 
ing of large quantities of mineral or metallic dust produces a definite 
pathological condition, primarily a fibrosis, known as anthracosis, 
silicosis, etc., according to the particular kind of dust involved. From 
the statistics collected by various authorities upon industrial hygiene it 
appears evident that the inhalation of most types of hard dust produces 
a marked predisposition to tuberculosis and other respiratory diseases. 
Among grinders, for example, "grinders' consumption" may account 
for four-fifths of the deaths from all causes. Coal dust, on the other 
hand, seems to exert a different effect. While the fibrosis due to the 
inhalation of most hard dusts predisposes both to pneumonia and 
tuberculosis, anthracosis predisposes to pneumonia but rather tends 
to promote immunity against tubercular infection. Ascher has par- 
ticularly emphasized the liability of those who breathe smoky air to 
respiratory diseases other than tuberculosis, and in comparing the 
death-rates in different localities a similar phenomenon has been noted, 
Pittsburgh and other smoky cities showing a high death-rate from 
pneumonia and a low death-rate from tuberculosis. 1 

The causation of hay fever and similar diseases by air-borne pollen 
is an excellent illustration of the possible harmful effects of almost 
infinitesimally small amounts of atmospheric solids of a specific 
nature. 

In many industries there are special health hazards due to the 
presence of intrinsically poisonous dusts and fumes such as carbon 
monoxide, methyl alcohol, sulphur dioxide, benzol and its compounds, 
lead and arsenic salts and the like. These, as well as the industrial 
dusts discussed above, are all localized problems of industrial hygiene 
which will be discussed under that heading in another place. They 
are to be dealt with less by general ventilating procedures than by the 
conduct of dusty operations within closed machinery, the special 
ventilation of grinding and buffing wheels and other dust-generating 
apparatus and the wearing of respirators by the workmen exposed. 
The dust in ordinary air, aside from such special factory hazards, has 
no general hygienic significance. 

1 For data in regard to the influence of dust upon disease see: Cohoe, B. A.: The 
Relation of Atmospheric Smoke and Health, Bull. No. 9, Smoke Investigation, Mellon 
Institute of Industrial Research and School of Specific Industries, Pittsburgh, 1914, p. 7. 
Haythorn, S. R.: Some Histological Evidences of the Disease Importance of Pul- 
monary Anthracosis, Jour. Med. Research, 1913, xxix (n. s. xxiv), 259. Hoffman, F. 
L: The Mortality from Consumption in Dusty Trades, Bulletin of the U. S. Bureau 
of Labor, No. 79, Washington, D. C, November, 1908, 1909, pp. 633-875. Hoffman, 
F. L. : Mortality from Consumption in Occupations Exposing to Municipal and General 
Organic Dust, Bulletin of the U. S. Bureau of Labor, No. 182, May, 1909, Washington, 
D. C, 1909, pp. 471-638. Klotz, O.: Pulmonary Anthracosis — A Community Disease, 
Am. Jour. Pub. Health, 1914, iv, 887. White, W. C, and Shuey, P.: The Influence 
of Smoke on Acute and Chronic Lung Infections, Trans. Am. Climatol. Assn., 1913; 
also Bulletin No. 9, Smoke Investigation, Mellon Institute of Industrial Research and 
School of Specific Industries, Pittsburgh, 1913, p. 164. 



260 AIR AND HEALTH— VENTILATION 

What Constitutes Good Air. — In view of the various influences of 
atmospheric conditions upon human life which have been discussed 
above, the essential requirements of good ventilation may be sum- 
marized as follows. 

1. The air should be cool but not too cold. For ordinary sedentary 
life in the schoolroom or the office a temperature between 65° and 68° 
F. should be maintained. In a factory where physical work is per- 
formed or in an open-air school where extra clothing is worn the tem- 
perature may be lower. Temperatures exceeding 68° (except in the 
case of aged and ill persons) produce discomfort, injure the vasomotor 
mechanism, decrease efficiency and predispose to respiratory disease. 
High temperatures combined with high humidities are particularly 
harmful. 

2. The air should be in gentle, but not excessive motion, and its 
temperature should fluctuate slightly from moment to moment. A 
moderate amount of air movement and temperature change keeps the 
surface of the body cool without chilling it and exerts a pleasantly 
stimulating effect upon the skin which is lacking either in stagnant air 
or in a steady warm current. 

It will be noted that the problems of ventilation are intimately 
related to those of clothing and bathing. In each case the chief aim 
should be to secure a healthy tone of the bloodvessels in the skin. 
Overheated rooms and too heavy clothing relax and weaken the muscles 
in the walls of these vessels. Chilly rooms, inadequate clothing and 
baths that are colder or more prolonged than the body can endure 
overstrain the heat-producing and heat-regulating machinery and 
produce the obscure reaction of " chill." Moderately cool, moving air, 
well-adapted clothing and cold baths within the limits of reaction, 
stimulate the vasomotor system and make it vigorous and efficient. 

3. The air should be free from offensive body odors. As a matter 
of public decency if not of public health it is desirable that school rooms 
and auditoria should not offend the noses of those who enter them from 
outside even though those who have been present while the odors were 
accumulating are usually unconscious of their presence. If the New 
York State Commission experiments on appetite are confirmed the 
presence of such odors may be unhygienic as well as unesthetic. 

4. The air should be free from poisonous and offensive fumes and 
large amounts of dust. 

Since the body possesses remarkable powers of adjustment to varying 
atmospheric conditions custom, and consequent adaptation, play a 
large part in our subjective symptoms and to some extent in the actual 
physiological effects produced. The power of acclimatization to miti- 
gate the primary symptoms of mountain sickness has been discussed 
above. With regard to temperature we undergo marked changes in 
our responses with the changing seasons. A warm day in May is much 
more debilitating than a hotter one in July, and a July atmosphere 
maintained indoors in December is much more harmful than either. 
So with odors, the olfactory mechanism quickly becomes dulled and 



PRACTICAL METHODS OF VENTILATION 261 

persons accustomed to close rooms endure conditions which would 
prove unbearable to those not inured to the influences of bad air. 

It is evident, however, from such studies as those of Professor 
Huntington that acclimatization to unfavorable atmospheric conditions 
is achieved in the long run at the cost of grave stresses of the physio- 
logical machine, and that the avoidance of such conditions warrants 
the most serious attention of the student of hygiene. 

PRACTICAL METHODS OF VENTILATION. 

Objects and Standards of Ventilation.— Practical provisions for the 
artificial ventilation of buildings have, in the past, been planned 
almost wholly with a view to maintaining the carbon dioxide content of 
the air below a certain level. It was assumed that the carbon dioxide, 
if not in itself poisonous, was an indirect measure of other chemical 
impurities and that if this constituent of the air were sufficiently diluted 
the aims of ventilation would be attained. 

On this assumption it is very easy to calculate how much air must be 
supplied for each occupant of any confined space. One formula com- 
monly used is as follows : 

n — p 

where Q = cubic feet of air needed per person per hour 

A = cubic feet of C0 2 produced per person per hour 
n = permissible concentration of C0 2 
p = concentration of C0 2 in atmospheric air 
The value n is an arbitrary standard fixed by the older hygienists 

at 6 to 8 parts per 10,000. Applying the lower of these limits 

Q = ~ nnn „ ' ~ - nnnn = 2000 cubic feet. 
0.0006 - 0.0003 

This calculation is the basis of the commonly accepted estimate of 
2000 cubic feet of air per hour (roughly 30 cubic feet per minute) as 
the amount necessary for good ventilation. The value of A is of course 
less for children than for adults and greater during vigorous exercise 
than when the persons in question are at rest. By taking account of 
these variations and above all by different estimates of the permissible 
C0 2 content (n) standards, have been derived varying from 400 cubic 
feet per hour per capita for schools to 5000 cubic feet per hour per 
capita for contagious disease hospitals. 

From such calculations of per capita air supply a second set of 
arbitrary constants has been devised to show the necessary allowance of 
cubic space per person in various occupied places. The air space 
allowance is calculated as one-third of the hourly air supply on the 
assumption (scarcely justified with modern ventilation equipment) 
that the air can be changed only three times an hour without producing 
objectionable drafts. The following table is an example of such a 
computation. 



262 



AIR AND HEALTH— VENTILATION 



Estimated Air Supply and Minimum Cubic Space Allowance. 

Air supply in 

cubic feet Air space 

Type of per capita per capita 

building. per hour. (cubic feet). 

Hospitals 2000-3500 700-1200 

Factories 1700 600 

Prisons 2000-3500 700-1200 

Theatres 1400-1700 500-600 

Halls and assembly-rooms .... 1000-2000 400-700 

Barracks 1000-1700 400-600 

Class-rooms for adults 800-1000 300-400 

Schools 500-700 200-250 

It should be pointed out that while a certain minimum air space 
is necessary to make ventilation possible, the existence of ample air 
space does not on the other hand offer any guarantee that ventilation 
is taking place. The absence of overcrowding makes it possible to 
introduce fresh air without creating drafts, but this is of no value if 
the fresh air is not actually introduced by some efficient means. Thus 
in a series of factories studied by the British Departmental Committee 
on Ventilation of Factories and Workshops which were classified accord- 
ing to their capacity in cubic feet per person, the highest mean carbon 
dioxide values were found in factories with over 5000 cubic feet per 
capita, the next highest value in those with less than 300 cubic feet. 
The general average of the 101 rooms with less than 1000 cubic feet 
per capita of air space was, however, a little higher than the average 
for 124 rooms with over 1000 cubic feet (10.5 parts per 10,000 against 
9.5 parts). 

In addition to the pollution from human sources the classic formulse 
for ventilation also took into account the carbon dioxide produced by 
illuminants of various sorts. Bergey in his Principles of Hygiene gives 
the following table in this connection. 



Vitiation of the Air by Human Beings and Illuminants. 









Development of 




Water vapor 


CO2 per hour 


Heat in 


in grams 


in liters. 


calories. 


per hour. 


Child 10.0 


52 


20 


Youth . . . 








17.0 


90 


40 


Man, resting 








20.0 


130 


60 


Man, working . 








36.0 


255 


130 


Candle . 








15.0 


106 


10-12 


Petroleum lamp 








56-61 


430-580 


35-40 


Oil lamp 








31-56 


200-390 


26-40 


Gaslight, flat burner 






90.0 


600-875 


130 


Gaslight, Argand b\ 


irne 


r 




109.0 


800-900 


157 



In view of our present-day knowledge of the relatively slight impor- 
tance of the chemical variations in the atmosphere, it seems unnecessary 
to lay great weight upon the standards based on such computations 
as those cited above. The student should be familiar with such figures 
and with their derivation, because they play so large a part in the 
literature of the subject. We are inclined today to be very lenient, 



PRACTICAL METHODS OF VENTILATION 263 

however, in regard to carbon dioxide standards. The British Depart- 
mental Committee on Ventilation of Factories and Workshops (1903- 
1907) recommended that the C0 2 standard be placed as high as 12 
parts per 10,000 during daylight and 20 parts when gas was burning. 
A standard of 12 parts would require an air supply of only 11 cubic 
feet per minute. 

Considering the problem of ventilation as primarily concerned with 
heat elimination rather than with carbon dioxide dilution, we can 
obtain our ventilation standards in another way. According to a low 
estimate (that of Pettenkofer) an adult gives off 400 British thermal 
units per hour. Let us assume that this heat must be removed by air 
entering the room at 60° and leaving it at not above 70°. One British 
thermal unit raises the temperature of about 50 cubic feet of air by 1°, 
or the temperature of 5 cubic feet of air from 60° to 70°. Hence, our 
average adult producing 400 British thermal units will require 2000 
cubic feet of air per hour at 60° to keep the surrounding temperature 
from rising. An ordinary gas burner produces 300 British thermal 
units per candlepower hour; therefore each such burner requires 
1500 cubic feet of air per candlepower. These calculations, of course, 
ignore direct heat loss through walls and ceiling which, with a zero 
temperature outside, may carry off the heat produced by 50 or 100 
people. In an interior auditorium, however, it is clear that an air 
supply of at least 30 cubic feet per capita per minute will be urgently 
required. In many industrial processes in which the heat produced 
by human beings and illuminants is reenforced by the friction of 
machinery and the heat from solder pots, furnaces, mangles, pressing 
irons or other similar sources the amount may have to be increased 
still further. 

The fact is that while 30 cubic feet per minute may be set as a rough 
standard often desirable to attain, it may be insufficient in certain 
cases and in many other cases may be an unnecessarily high figure. 
Hygienists must insist on standards of air conditions actually main- 
tained rather than on any arbitrary mechanical standards assumed to 
be capable of maintaining them. Any system which does not guard 
against overheating is inadequate, however large a volume of air may 
be forced into the room. 

In order to avoid malodorous conditions we may fairly demand a 
certain minimum of air change. In addition, however, we must supply 
enough air at such a temperature as to prevent the room atmosphere 
from rising materially above 68°. 

Heating and Ventilation. — It is obviously impossible to consider 
ventilation intelligently without considering heating as well, since the 
main object of ventilation is to avoid overheating. There are three 
methods of heating rooms which are in common use: (1) Direct 
heating is effected by radiators or other heat sources within the room 
itself; (2) indirect heating is effected by supplying to the room air 
which has been previously heated elsewhere as by a furnace or a 
plenum- ventilation plant; (3) direct-indirect heating is a combination 



2G4 



AIR AND HEALTH— VENTILATION 



of the other two in which part of the heat of the room is supplied by 
warm air entering it and part by local radiators. 

With direct heating alone some other provision must be made for 
the air supply necessary to prevent the accumulation of stale odors. 
With indirect or direct-indirect heating, on the other hand, as com- 
monly practised in schools and other public buildings, it is common to 
find that the supply of air is more than ample, but that its temperature 
is so high as to produce a harmful degree of overheating. 







Fig. 26.- 



-Types of thermostats for automatic temperature regulation, 
and Ohmes.) 



(Kimball, Lyle 



Either direct or indirect systems of heating can be controlled by 
automatic thermostats. These are devices in which the differential 
expansion of two suitable metals controls radiator valves or dampers 
in the air ducts. When in good working order such thermostatic 
systems are highly efficient. In a certain mechanically ventilated 
school in New York City, for example, where the thermostats were so 
adjusted as to supply air at 60°, 143 different observations of the room 
air showed 124 records between 64° and 69°, with 3 below 64° and only 



PRACTICAL METHODS OF VENTILATION 265 

3 above 71°. On the other hand it must be recognized that thermo- 
static systems very easily get out of order. When the same school 
cited above was visited a few years later its temperature control was 
found to be so imperfect that the experiments contemplated had to be 
transferred to another building. In a New York office building, studied 
by the writer, 85 offices and workrooms had thermostatic and 147 
hand control. There was somewhat greater overheating in the "auto- 
matically controlled" rooms than in the others. In one particular 
room the temperature for a period of twenty-one days in February 
and March never fell as low as 70° during working hours, and was 
usually in the neighborhood of 80°. The reason was apparent when 
it was found that of 213 thermostats in this building, which were 
individually examined, 110, or 52 per cent., were out of order and not 
controlling their radiators. 

It is obvious that the maintenance of heating systems so that they 
shall not by their own pernicious activities produce undesirable con- 
ditions of excessive temperature is the first task of ventilation. 

Natural Ventilation. — In addition to the control of overheating due 
to the abnormal functioning of artificial heat sources, it is also essential, 
as pointed out above, to provide in all enclosed spaces sufficient fresh 
cool air to prevent the accumulation of stale odors and to remove any 
excess of heat produced by the vital activities of the occupants and by 
processes of combustion. 

This necessary change of air is brought about in all cases, to a greater 
or less extent, by agencies of natural ventilation. In cold weather, 
occupied buildings are warmer than the outside air and the difference 
of temperature produces a chimney action, the warm air escaping from 
the upper parts of the building and cool air being drawn in below to 
take its place. Wind pressure accentuates this action and in warm 
weather this force alone may ensure a considerable circulation of the air. 

Even in closed rooms the change of air produced by natural venti- 
lation may be surprisingly large. Marker and Schultze report that 
from 4 to 8 cubic feet of air per hour may pass through a square yard 
of sandstone, limestone or brick with a temperature difference between 
inside and outside air of 9.5° F. The First British Departmental 
Report on Ventilation of Factories and Workshops (1903) gives some 
interesting data on this point, obtained by burning candles of known 
weight (yielding a known amount of carbon dioxide) and estimating 
the air change by the carbon dioxide content of the room air at the end 
of specified periods. In a large laboratory room with two double 
windows and one outside wall of sandstone, one inside wall of brick, 
one of sandstone and one of wood and plaster, with a temperature 
difference between inside and outside air of 4° to 9° F., and almost no 
wind, the room air was completely changed every four or five hours. 
In rooms with fireplaces the air was changed in one or two hours. 
With windows open the ventilation may, of course, be increased to 
almost any degree, depending on variations of temperature and wind 
pressure. 



266 AIR AND HEALTH— VENTILATION 

In dwelling houses where there is no overcrowding natural venti- 
lation of this kind is amply sufficient for all practical purposes. In 
schools, factories and auditoria on the other hand, where the occupants 
are crowded together, this procedure is likely to prove inadequate. 
When the air outside is nearly as warm as that indoors the temperature 
differences, unless a strong wind is blowing, will provide an altogether 
insufficient supply of air to remove either body odors or excess heat 
produced in a crowded room. In cold weather, on the other hand, 
insuperable difficulties arise as a result of inequalities of distribution. 
In a school or a factory where there is a row of five or ten or twenty 
persons extending from a window across to the inner wall of the room 
it is out of the question to ventilate by admitting the untempered air 
of winter through that window. Either the temperature near the 
window will fall so low as to chill those in that vicinity or the tempera- 
ture at the other side of the room will rise too high, the latter result 
being the more usual one. 

The maintenance of " open-air" schoolrooms at a temperature of 
50° F., or thereabouts is a special problem by itself. From a mechanical 
standpoint there is, of course, no difficulty in leaving windows open, 
" unhousing," to use a picturesque phrase which has been applied to 
this process. Open-air treatment appears to be highly desirable for 
subnormal children, particularly when combined, as it usually is, with 
provision for special clothing and feeding and short hours and rest 
periods and special exercises. Without such additional provisions, 
which are essential for the physically defective but costly and difficult 
of general application, it is probable that the maintenance of tempera- 
tures much below 65° is harmful rather than beneficial. 

Natural ventilation, then, works well in the home and works badly 
in a schoolroom that is designed to be kept at a temperature between 
65° and 68°. In the studies of the New York State Commission on 
Ventilation it was found quite impossible to maintain satisfactory 
conditions in such schoolrooms by means of window ventilation alone, 
unless special provision was made for tempering the incoming air and 
for the egress of stale heated air through special ducts. The cloth 
window screens which have been advocated by some school authorities 
for moderating the amount of the incoming air proved particularly 
unsatisfactory in these experiments. 

The hospital ward appears generally to fall in the same category 
as the living room from the standpoint of the efficacy of simple window 
ventilation. Patients are, for the most part, in bed or at least warmly 
clad and under control. Overcrowding is not great, and constant 
intelligent watchfulness of the extent to which windows are opened 
is easily possible. 

The Fairfield System of Modified Window Ventilation. — An 
ingenious and simple system of modified window ventilation, devised 
by Mr. S. H. Wheeler of Bridgeport, Conn., and first installed at the 
Sherman School, Fairfield, Conn., eliminates the disadvantages of the 
ordinary natural ventilation while retaining some of its peculiar ad- 



PRACTICAL METHODS OF VEXTILATIOX 



267 



vantages. According to this plan fresh air is admitted through the 
windows, but direct drafts are prevented by placing slanting window 
boards on the sashes so that the incoming air is deflected upward and 
mixed with the general air of the room. This incoming current is 
furthermore tempered by placing the radiators used for direct heating 
under the windows and by making these radiators large enough to 
extend over the entire width of all the windows (Fig. 27). Finally, a 
duct is provided for the egress of warm, vitiated air passing from near 
the ceiling of each room to the outer air, the upward current in this 
duct being maintained by the temperature difference between the out- 
door and indoor air. 

In industrial establishments where crowding is not great the same 
general principle has been applied by providing special air inlets to 
individual rooms with heating coils placed directly in front of them. 




Fig. 27. — A window-ventilated schoolroom (Fairfield, Conn.). Notice the plates which 
deflect the air upward and the long radiators under the windows. 

An interesting system of ventilation, known as the King system, is 
in use in cow stables, which secures much better air conditions than 
those to which human beings are frequently exposed. Louvred open- 
ings at the ridge pole furnish an exit for the warm, vitiated air, while 
fresh air is admitted through ducts in the walls. These ducts open to 
the outside at the bottom of the wall and to the inside of the stable 
four or five feet above the floor, the inflowing current of air being 
induced by the difference in temperature between the stable and the 
outer air. 

With provision for tempering the incoming air, and with gravity 
exhaust ducts for the outgoing air, modified natural ventilation works 
very satisfactorily in many schools and in certain factory workrooms. 
Some schools, however, are so situated with reference to dusty or noisy 
streets that open windows are out of the question; and in crowded 
factories, particularly those in which heat is contributed by the indus- 



268 



AIR AND HEALTH— VENTILATION 



trial processes themselves, some more intensive method of ventilation 
is essential. In anditoria where crowding is great and the distance to 
the outer walls considerable, natural or gravity ventilation is almost 
always inadequate. In such cases we must resort to forced or mechani- 
cal ventilation involving the use of fans. 




Fig. 28. — Propeller fan. (Kimball, Lyle and Ohmes.) 




Fig. 29. — Centrifugal fan, ordinary- 



Sirocco" type; showing suction eye and fan wheel 
in position. 



Forced or Mechanical Ventilation Involving the Use of Fans. — Two 

general types of fans are used in securing forced ventilation: The 
propeller type of fan (Fig. 28) works in the open and drives the air at 
right angles to the general plane in which the fan itself revolves. This 
form of fan will move considerable volumes of air but only against low 
pressures, and is well adapted to supplement natural ventilation when 
only a moderate increase in air change is essential. Propeller fans are 
often placed in the outer walls of workrooms for example, discharging 
outward, to accelerate natural agencies in the exhaustion of vitiated 



PRACTICAL METHODS OF VENTILATION 269 

air. Such fans are not, however, suited for use with duct systems of 
ventilation where the air must be moved against considerable pressure. 
When the pressure rises their efficiency falls off and a back current is 
often created, the air flowing in one direction at the periphery and in 
the opposite direction near the center of the fan. 

For systems of duct ventilation the centrifugal type of blower fan 
is used (Fig 29) . The air is drawn in by the central opening at the side 
and forced out by the revolution of the blades through the duct shown 
at the left. Fans of this pattern may be used as pressure or plenum 
fans when they deliver to the ventilating ducts and draw in their 
supply freely from an air chamber surrounding them. Or they may be 
used as exhaust fans if the central opening is connected to the ventilating 
ducts and the delivery is to the outer air. In some buildings with very 
elaborate plans for ventilation both plenum and exhaust fans and ducts 
are provided. 

It is important in planning for plenum ventilation that the air should 
be taken in at such a point as to be protected from special sources 
of odors and dust. The writer recalls the case of an admirably equipped 
hospital where there was much complaint of stale odors when the 
mechanical ventilating plant was used. It developed on examination 
that the fresh air intake on the roof was placed close beside the opening 
of the soil pipe of the plumbing system and was sucking out the air 
of the house drain and transferring it to the wards. 

Plenum ventilation is often combined with air washing or artificial 
humidification, and the general arrangement of the inlet end of a fully- 
equipped plenum system of ventilation and humidification is shown in 
Fig. 30. The fan draws its air from the fan chamber and forces it out 
through the duct at the right, the suction which it exerts producing a 
constant vacuum in the chamber, which draws in fresh air from outside 
through the screen at the left. In passing from this screen to the fan 
the incoming air is first heated to a moderate degree (50° to 70° F., 
depending on various conditions) by passing through the tempering 
coils, which are lines of steam piping like those in an ordinary radiator, 
but so constructed as to present the largest possible surface to the 
rapidly moving air. From the tempering coils the warmed air passes 
through the spray chamber or humidifier. This is a chamber filled with 
a fine mist of water produced by some form of spray discharge, and at 
its outlet end the air passes between a series of overlapping eliminator 
plates or baffles which change its direction suddenly many times. 
Contact with these baffle plates removes the excess of moisture which 
drains off from the eliminator to a collecting pan below. 

Three things occur in the spray chamber, when it operates successfully. 
The air is humidified nearly to the point of saturation. It is cooled by 
the loss of the amount of heat required to transform the water taken 
up from the liquid to the gaseous form (5° to 10° in summer time), 
and it is washed free from a portion of its suspended dust particles. 1 

1 Much simpler systems of humidification are sometimes installed in which moisture 
is supplied by evaporation from moist surfaces over which the incoming air is allowed 
to pass without the production of fine aerial spray. 



270 



AIR AND HEALTH— VENTILATION 



Finally, on Leaving the spray chamber the air passes through a second 
set of heating coils, where its temperature is brought up to the final 




I 3-/ * "A ' 



PRACTICAL METHODS OF VENTILATION 



271 



point desired, ranging from perhaps 60° F., where the removal of the 
heat produced in an auditorium is necessary to 150°, where a large 
amount of indirect heating must be accomplished. 




The temperature of the air delivered by the fan may be regulated 
automatically by thermostats controlling either sections of the heating 
coils or dampers which admit a varying proportion of by-passed air, 
not passed through the heating coils at all, The humidity of the air 



272 AIR AND HEALTH— VENTILATION 

delivered can be regulated by controlling the relative temperatures of 
the tempering and the final heating coils since the air passing the 
humidifier is supposed to be saturated at the temperature at which it 
[eaves the spray chamber and its final humidity will obviously depend 
on the increase in temperature to which it is subjected after this point. 

In plenum ventilation without humidification, which is the more 
usual plan, spray chamber and eliminator plates are omitted, but the 
fan chamber tempering coils and heating coils remain as shown in 
Fig. 30. From the fan chamber the air is forced to various parts of 
the building by a system of ducts such as is shown in Fig. 31. It is 
impossible here to go into the details of duct construction, but it may 
be pointed out that many systems of fan ventilation in actual use 
fail to give satisfactory results because the ducts are so imperfectly 
proportioned as to distribute the air unevenly between the different 
parts of the building. Thus in one office building studied by the writer 
an exhaust system was installed which gave reasonably good results 
on the six lower floors, while on the upper floors there was either no air 
flow at all or vitiated air from the lower part of the building was being 
forced into the room through the supposed exhaust ducts. The problem 
of the proper proportioning of air ducts is by no means a simple one, 
as emphasized particularly by the studies presented in the Second 
Report of the British Departmental Committee on the Ventilation 
of Factories and Workshops (1907). It is important that individual 
duct dampers should be provided so that the air supply to each room 
can be independently controlled; and by somewhat elaborate but 
wholly practical systems of double or individual duct ventilation even 
the temperatures of each room can be separately controlled to meet 
varying conditions of weather and occupancy. 

The linear velocity of air maintained in systems of fan ventilation 
will usually vary from 1200 to 2000 feet per minute in the main duct 
near the fan. As the air passes through horizontal branch ducts and 
vertical stacks its velocity is gradually reduced and at room inlets it 
is usually between 300 and 800 feet per minute. It is desirable that it 
should not exceed 300 feet per minute at such points in order to avoid 
unpleasant drafts. In order therefore to provide the air supply of 30 
cubic feet per minute commonly believed to be necessary the inlet 
registers in any room should have a total area equal to 0.1 square foot 
per capita. 

Distribution of Air Within the Room. — In addition to providing a 
given total amount of air to the room to be ventilated, considered as a 
unit, it is important to secure a reasonably equable distribution of 
air within the different parts of the room itself. Local temperature 
differences and other factors which affect this distribution are complex 
and variable. It is by no means rare to observe grotesque mistakes 
in actual practice such, for example, as an exhaust fan of the propeller 
type placed over an open window producing a strong local up current 
with no material benefit to the room as a whole. In inspecting a venti- 
lating plant special attention should always be paid to this problem. 



PRACTICAL METHODS OF VENTILATION 



273 



The diagrams reproduced in Fig. 32 illustrate the marked variations 
in air distribution which commonly occur as revealed in studies carried 
out by the New York State Commission on Ventilation. 

Direction taken by warm and co/d streams of otr* 
entering- a room. 

This is <x verttcol section oPfhe. room &/rec.6/t//n 

front of in/e t. Temioeratares(fhhr) are noted ot different /Points 




r^/oor- JO" 

E*ire/?istG /ft* colds* rn/w KboM /7/W. 



Cc// 



6S' 



tsr 




SIS * J^/oor J~6 ' 

//^r£/rwff /ft* wM*?»t/c:j? TtftM Room /?/&. 

Fig. 32. — Diagram illustrating inequalitiesjin the distribution of air within a room. 
(New York State Commission on Ventilation.) 

There are two general systems of room air supply in common use, the 
upward and the downward system. The latter plan, which is usually 
employed in schoolrooms, brings the fresh air in at the top of the inner 
or warm wall of the room and takes out the vitiated air at the bottom 
of the same wall. It is assumed in such a system that heating is com- 
18 



274 AIR AND HEALTH— VENTILATION 

bincd with ventilation and that the incoming air will be warmer than 
the general room air. If this is the case the warm fresh air will pass 
across the upper half of the room (see lower chart in Fig. 32) and on 
striking the outer wall' will be cooled and will drop to the floor and 
recross the room to the exhaust outlets. 

If ventilation is frankly recognized as a procedure for supplying 
fresh, cool air to remove the excess heat produced within a confined 
space, an upward system of ventilation seems more logical. This plan 
involves the introduction at or near the floor of air cooler than the 
general air of the room, this air to become gradually warmed as it 
rises to exhaust outlets at the ceiling. This is the system commonly 
employed in ventilating crowded auditoria. In order to avoid unpleas- 
ant drafts the admission of air cooler than that of the room must 
generally be accomplished through multiple inlets which in auditorium 
ventilation are often placed under each seat; and even with this 
arrangement complaints of draft are frequent. 

With window ventilation on the Fairfield plan the exhaust outlet 
should of course be placed near the ceiling on the inner side of the 
room, the general course of the air flow being inward and upward. 

Choice of a Method of Ventilation. — It cannot be too strongly 
emphasized that there is no "system" of ventilation which will ensure 
universally satisfactory results, any more than there is any "system" 
of medical treatment which will cure all diseases. Each building, and 
to some extent each room, furnishes problems of its own which ought 
to be studied by a competent heating-and-ventilating engineer in 
order to ensure satisfactory and economical results. 

In the hospital w r ard, as pointed out above, window ventilation 
alone may suffice. In the schoolroom either modified ventilation on 
the Fairfield plan or plenum fan ventilation may prove most satis- 
factory. The New York State Commission on Ventilation has con- 
ducted extensive studies on the comparative results attained by these 
two general methods of ventilation without very striking differences 
being observed. On the whole the fan system as might be expected 
changed the air more frequently and showed somewhat lower carbon 
dioxide values. Probably as a result of the more rapid air change with 
resulting drafts the temperature of fan- ventilated rooms is generally kept 
a little higher than that of window- ventilated rooms. There was a some- 
what surprising unanimity of opinion among the observers on the staff of 
the Commission as to the pleasanter quality of the air in the window- 
ventilated rooms. This may perhaps have been due to the fact that the 
temperature and movement of the air in the fan rooms were relatively 
constant, while the air of the window-ventilated rooms was in slight, 
but variable motion and at any given point showed slight fluctuations 
of temperature from minute to minute. It is possible that this quality 
of variability may be an important factor in the agreeableness of the 
atmospheric conditions which surround the body. 

The most striking difference noted between window- and fan-venti- 
lated rooms was the difference in the incidence of respiratory disease 
cited on p. 254. The figures for this study have been there analyzed 



PRACTICAL METHODS OF VENTILATION 



275 



by dividing the rooms into classes according to the temperatures main- 
tained in them. From the standpoint of practical ventilation methods 
the rooms were of three types : Group A, ventilated by open windows 
and kept at a temperature between 50° and 60°; Group B, ventilated 
by windows but kept at about 68°; Group C, ventilated by the plenum 
system with windows closed and kept at about the same temperature 
as Group B. It was intended that Groups B and C should differ only 
in the method of ventilation but as a matter of fact the temperatures 
averaged slightly higher in the fan- ventilated group. The prevalence 



£3 



Type Of 
\Entilation 



1916 


I9I6-/9I7 






V^A 




\I3.I | — 
















\io&\ 




\/o&\ 




laol 




\lU.b | 



Absence Due To 
Respiratory Sickness 



5 io\ 
< <q e 

T 10 
"0 1*4 

Ct^ 4, 

Type Of 

\tNTILATION 



19/6 



1 91 6-1917 



[gw 



I 



Respiratory Sickness 
Among Students In Attendance 



Fig. 33. — Effect of ventilation conditions upon respiratory sickness, plotted from 
data obtained by Dr. S. Josephine Baker in cooperation with the New York State 
Commission on Ventilation. 



of respiratory disease was materially greater in Group C than in Group 
B as shown in Fig. 33. The differences which appear when the rooms 
are thus classified according to ventilation methods, irrespective of 
temperature, are essentially the same as those which appear when they 
are classified by temperature irrespective of method of ventilation 
(see Table on p. 254), the fan rooms including most of the overheated 
rooms and vice versa. It is difficult therefore to say whether the excess 
of respiratory disease in Group 3 on p. 254 and in Group C in Fig. 33 
was due to overheating alone or in part to some other factor, such as 
temperature variability or type of air movement associated with 



271) 



AIR AND HEALTH— VENTILATION 



plenum ventilation. In any case, however, the study presents the 
system of window ventilation in a very favorable light. 

We should avoid, however, the tendency to accept the Fairfield 
system of window ventilation as a panacea. It works most satis- 
factorily under certain conditions; under other conditions, in a school 



-i Leg end *- 

Thermostat Control 

-Hand Control 

Public School *33 




60 



6Z 



6+ 66 66 70 1Z 

Degrees Fahrenh&t 



14 



76 18 



80 



Fig. 34. — Distribution of temperatures in a schoolroom effectively controlled by 
thermostats, and in two sets of workrooms, one with hand control, the other controlled 
by a thermostatic system in bad repair. 



for example, whose windows can be opened only on a dirty, noisy city 
street, fan ventilation may be essential. In crowded auditoria and in 
many factories fan ventilation is certainly the only type of system 
which will yield the necessary results. 

Recirculation. — The recognition that ventilation is not primarily a 
problem of removing toxic substances but rather one of air conditioning 






PRACTICAL METHODS OF VENTILATION 277 

from the standpoint of temperature and humidity has led to the very 
interesting suggestion of applying the principle of recirculation to the 
air of occupied spaces. In applying such a plan the air exhausted from 
a room is not discharged into the outer air but carried back to the fan 
room where it is washed by passing it through a humidifier such as 
has been described above and after its temperature and humidity have 
been adjusted it is sent back again to the rooms, mixed with a greater 
or less proportion of fresh outside air. The waste of coal involved in 
the discharge of exhaust air from ventilating ducts is of course enormous 
and a system like that of recirculation which promises to save from 
one-third to one-half of our heating costs has naturally received very 
serious consideration. 

Dr. J. H. McCurdy and Prof. F. H. Bass have reported very satis- 
factory results from the use of recirculated air, in the Y. M. C. A. 
College Gymnasium at Springfield, Mass., and in a school at Minne- 
apolis, Minn., respectively. 1 On the other hand, studies conducted by 
the New York State Commission on Ventilation in a New York City 
school have been distinctly unfavorable to the process. Even with 
most careful operation it was found impossible to keep the recirculated 
air constantly free from body odors by the use of the air washer; and 
the deodorization of the air with ozone, a process which has been 
strenuously advocated in recent years, proved even more unsatisfactory. 
The unpleasant smell of the ozone was added to the body odor without 
obliterating it. Incidentally it may be remarked that the use of ozone 
in ventilation is without scientific justification. It cannot disinfect 
air except in concentrations which are physiologically harmful, and 
its deodorizing effect is of very uncertain value. Recirculation may be 
well adapted to certain installations, as at Springfield where it has 
worked most satisfactorily. To advocate it as a general procedure for 
school ventilation, under the conditions of operation likely to obtain 
the country over, would seem to be unwise. 

Artificial Cooling. — One application of ventilation principles which 
deserves far more attention than it generally receives is the possibility 
of artificial cooling of the air of occupied spaces in warm weather. It is 
somewhat strange that we freely pour out money to heat, and often 
to overheat, our buildings in winter while we so seldom think of cooling 
them in summer. Yet one procedure is quite as practical as the other 
(though more expensive) and perhaps quite as important from the 
standpoint of hygiene. 

The passage of air through a humidifier, as pointed out above, effects 
an appreciable degree of cooling; or the incoming air may be cooled by 
passing it over coils through which cold water or brine is circulated. 
One of the leading banking houses of New York is provided with a 
system of ventilation used in this way for heating in winter and for 

1 Bass, F. : The Recirculating of Air in a Schoolroom in Minneapolis, Trans, of the 
Am. Soc. of Heating and Ventilating Engineers, 1915, xxi, 109-125. McCurdy, J. H.: 
Gymnasium Ventilation Results, Heating and Ventilating Magazine, 1913, No. 11, x, 
26-32. 



278 AIR AND HEALTH—VENTILATION 

cooling in summer. A temperature about 10° below that of the outside 
air is maintained in warm weather, and the writer was told by a mem- 
ber of the firm that there was only one serious objection to the plant — 
that people who came into the office in summer could never be per- 
suaded to finish their business and go out again. One of the principal 
hotels in Chicago has an artificially-cooled dining-room that is a 
constant satisfaction to those who visit it. The Mt. Sinai Hospital 
in New York has provided a specially cooled room for young children 
and in view of the direct relation between heat and infant mortality 
this would seem to be a particularly important application. It seems 
likely that cooling of the air of occupied spaces in warm weather is 
likely to be much more extensively developed in the future. 

The Factor of Operation. — In all problems of ventilation the factor 
of faithful and intelligent operation is essential to success. No amount 
of skilful planning will produce a system that can work itself. Window 
ventilation requires the constant attention of those in charge of indi- 
vidual rooms. The most elaborate system of plenum ventilation, with 
automatic temperature regulation, must be constantly watched to 
see that all its parts are in good w T orking order. Constant vigilance is 
the price of pleasant and wholesome air conditions. 

When a new plant of any kind is installed it should be operated for a 
time under the supervision of its designer, w r ith careful studies of results, 
as regards temperature and humidity and air circulation in different 
rooms and parts of rooms. Such preliminary tests would reveal many 
minor adjustments likely to improve results materially; and they 
would make it possible to formulate clear and simple rules of operation 
which could be turned over to the janitor or other operating agent 
with reasonable assurance of success. 

The Value of Outdoor Air. — Artificial methods of ventilation 
serve to correct the objectionable conditions of densely occupied rooms 
and to mitigate the extremes of inclement outdoor weather. No 
system of indoor air conditioning can, however, equal the outdoor air 
at its best. Cool open air, fresh and clean and in stimulating motion 
is the best stimulant for the skin and, w r ith the exercise which accom- 
panies outdoor life, one of the most useful tonics for the whole body. 

Windows should therefore be kept open whenever it is possible to 
do so without harmful drafts irrespective of other systems of venti- 
lation. In the schoolroom it is often found most helpful to throw 
open the windows for five minutes in the middle of the session while 
the pupils move about or exercise in order to keep warm. The stimulus 
of the cold-air bath will more than make up for the lost time; and 
even in factories such a procedure may prove of practical advantage. 

It is particularly important to have plenty of fresh air in the sleeping 
ioom. We do not wholly understand why the impact of cold air 
on the face, with the rest of the body warmly covered, should be 
beneficial, but experience clearly shows that such is the case. Windows 
should, therefore, be always open in the sleeping room even in the 
coldest weather, or the bed placed on a sleeping porch outside. 



TESTING OF VENTILATING EQUIPMENT 279 

THE EXAMINATION OF AIR AND THE TESTING OF VENTILATING 

EQUIPMENT. 

Points to be Covered in a Ventilation Survey.— In studying the air 
conditions in a school or factory or other building, the health officer 
should first of all obtain a clear idea of the general plan adopted for 
heating and ventilation, the number of ducts installed for supply and 
exhaust, and the system, if any, of temperature control. The mechani- 
cal constants of the situation should then be determined, including 
the number of occupants in various rooms and the approximate cubic 
space per capita. If there is a mechanical ventilating plant its con- 
struction and operation should be studied in detail. Velocity of air flow 
and cubic feet of air supply per capita (based on the population served 
by each main duct) should be determined when possible by direct 
measurements in each main duct. The room registers should be 
measured and their per capita area calculated. As pointed out above, 
this area should equal about 0.1 square foot per capita. In one case 
studied by the writer 31 per cent, of the register areas in an office 
building were inadequate and 54 per cent, unnecessarily large. The 
air flow at the registers should be measured by means of an anemometer 
and checked up by measurements of the flow in the main ventilating 
ducts and studies of the rated capacity and actual performance of the 
fans. Sometimes the fans will be found to be of a totally inadequate 
type. Sometimes they can be made effective by simple changes in 
pulleys or motors which will permit of an increased speed. Sometimes 
trouble arises from the fact that the engineer is saving coal by operating 
the fans at reduced speed or not at all. Sometimes the fan is doing its 
part, while wrong proportioning of register areas and the lack of volume 
dampers distribute the pressure so faultily that the air is changed too 
rapidly in one section and too slowly in another. In a large dining 
hall studied by the writer the exhaust at the end of the room near 
the fan was 26 to 33 cubic feet per capita, a very satisfactory value, 
while at the other end of the room it was 7 to 9 cubic feet. 

Determinations of carbon dioxide are very helpful as a check on 
these mechanical measurements, for carbon dioxide is undoubtedly a 
good measure of the amount of air change which is going on. The 
table on p. 280, in which the rooms in a large office building have been 
grouped in four classes according to their provision of duct and window 
ventilation, shows how well the carbon dioxide values coincide with 
actual ventilation conditions. 

The most important of all steps in a ventilation survey is to obtain 
an accurate idea of the temperature conditions which are actually 
being maintained. This can best be done by installing automatic 
recording thermometers in typical rooms, although such continuous 
records should always be supplemented by occasional direct records of 
temperature and humidity made with the sling psychrometer. 

The results of such a study can most conveniently be plotted on a 
distribution curve with temperatures as abscissae and percentage of 



280 



MR AND HEALTH— VENTILATION 



observations in each class as ordinates. The proportion of records 
above certain temperature limits will give a fair idea of the extent of 
overheating. 

Relation of Artificial and Natural Ventilation to Air Con- 
ditions, New York Office Building. Xoiber of Rooms of 
Each Type Showing a Given Carbon Dioxide Content. 



Carbon dioxide parts per 10,000. 



6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


8 


6 


2 
















1 


2 


1 


1 














12 


14 


11 


2 


2 




1 


1 






3 


6 


6 


4 


13 


11 


5 


6 


2 





10 



Rooms with exhaust over 30 cu. ft., 

window openings over 0.25 sq. ft. 

P- c 

Rooms with exhaust over 30 cu. ft., 

window openings under 0.25 sq. ft. 

P- c 

Rooms with exhaust under 30 cu. ft., 

window openings over 0.25 sq. ft. 

P- c 

Rooms with exhaust under 30 cu. ft., 

window openings under . 25 sq. ft. 

p. c 1 



5 9 



Determinations of aerial dust and bacteria may be desirable in certain 
special cases. 

The methods of making the various observations discussed above are 
described in detail in the Final Report of the Committee on Standard 
Methods for the Examination of Air of the Laboratory Section ot the 
American Public Health Association, 1 and in a paper by D. D. Kimball, 
J. I. Lyle and A. K. Ohmes on the Testing of Atmospheric Conditions 
and Heating and Ventilating Equipment; 2 and it is upon these two 
reports that the following brief discussion of the procedures will be 
based. 

Measurement of Air Flow.— The flow of air can be measured in two 
ways, by direct measurement with the anemometer and by determining 
the energy of the moving air current by the use of manometers. The 
Pitot tube is the commonest example of the latter type of instru- 
ment ; 3 but its use requires considerable technical skill and for ordinary 
purposes the anemometer may be employed. 

A typical anemometer is" shown in Fig. 35. The ordinary instrument 
is reasonably accurate within a range of velocities of from 2 to 20 feet 
per second, but since the readings obtained are dependent on the 
friction of moving parts the anemometer must be frequently recali- 
brated and corrections applied to the recorded velocities. Rough 



1 Am. Jour, of Pub. Health, 1917, No. 1, vol. vii. 

2 Presented at semi-annual meeting of The American Society of Heating and Engi- 
neers, Chicago, July 18, 1917; reissued by the society, October 1, 1917. 

3 For a discussion of this instrument see Report of a Committee on Standardization 
of the Use of the Pitot Tube, Trans, of the Am. Soc. of Heating and Ventilating Engi- 
neers 1914, xx, 210-215. 



TESTING OF VENTILATING EQUIPMENT 2S1 

preliminary observations may be made by moving the anemometer 

slowly back and forth over the entire area of air flow but in final 
determinations the instrument should not he moved about, as part 
of the momentum of the movement is translated into revolution of the 
vanes. The following procedure should be followed as recommended 
in a report of the Committee on the Best Way to Take Anemometer 
Readings: 1 




Fig. 35. — Typical anemometer. (Kimball. Lyle and Ohmes.) 

1. The opening shall be divided into equal rectangular areas, no 
side of which shall be over 10 inches long, excepting where this would 
require more than ten readings, in which case the opening shall be 
divided into twelve equal areas. 

2. Readings are to be taken in every case at the center of every 
area. 

3. Readings are to be of one-half minute duration, the anemometer 
being held at the register base or in the plane of the opening. 

4. Where the diffusers are used, a total area is to be computed on the 
basis of the periphery of the diftuser. 

5. The average of the readings is to be considered as the average 
velocity at the opening. Where negative velocities are found, they are 
to be deducted in arriving at the average velocity. 

6. In computing volume, the net area of opening is to be taken, the 
volume to be considered as the product of the average velocity and the 
net area of the opening. 

7. If the anemometer is held two inches from the register face, no 
deduction shall be made for the area occupied by the register mesh. 

Currents of air within the room which are of too slight velocity to 

1 Transactions of the American Society of Heating and Ventilating Engineers, 1913, 
xix, 202. 



282 



AIR AND HEALTH— VENTILATION 



be measured by the anemometer may be studied by the use of colored 
fumes, smoke from joss-sticks, specially delicate anemometers, paper 
streamers or other methods adapted to local needs. 

Determination of Carbon Dioxide. — The Petterson-Palmquist appa- 
ratus has been generally accepted as standard for the determination 
of carbon dioxide in American sanitary investigations. It can now be 
obtained from Eimer and Amend and many other dealers. In the 
hands of a skilled operater an analysis can be obtained in five minutes, 
and for careful work this seems to be the best instrument available. 
The principle involved is the measurement of a given volume of air, 
the absorption of the contained carbon dioxide in caustic potash 
solution, and the remeasurement of the volume of air at the original 
pressure in a finely graduated capillary tube, the difference in volume 
representing the absorbed carbon dioxide. The instrument must be 
carefully adjusted to maintain a uniform temperature and pressure, 
and the details of manipulation can only be mastered by considerable 
practice with the instrument in hand. 













1 


f 








T 

T 


I 

























Fig. 36. — Apparatus used for determining the carbon dioxide content of air. 

The Petterson-Palmquist apparatus is large and cumbrous for field 
investigations and in such places as street cars its employment would 
be out of the question. It may often, therefore, be best to collect the 
samples in the field and bring them back to the laboratory for exami- 
nation. The Committee on Standard Methods for the Examination 
of Air recommends the following procedure: 

" Samples are collected in two-ounce, glass-stoppered bottles of clear 
glass if the analysis is not made with the portable apparatus on the spot. 



TESTING OF VENTILATING EQUIPMENT 283 

These bottles hold about 70 c.c, which is enough air to make two 
analyses, in case it should be necessary — and it is always advisable — 
to repeat determinations. The stopper of each bottle is greased with 
petrolatum, or with a mixture of petrolatum and soft paraffin which 
will spread readily under pressure; and after the sample is taken, the 
stopper should be turned round and pressed down until no air channels 
are visible in the petrolatum. The stopper is held in position by a stout 
elastic band passed over it and a gummed label is placed on the bottle. 

"The bottles must be dry, and they should be clean. They should 
be rinsed with clean (preferably distilled) water and completely dried. 
If a bottle is wet and dirty an appreciable amount of CO2 may be 
produced or some may disappear by bacterial action. If, on the other 
hand, the bottle is wet and clean, carbonic acid gradually disappears, 
as it is absorbed by alkali dissolved out of the glass by water. In dry 
bottles, even though dusty inside, no sensible alteration takes place 
within a fortnight or more. 

"The sample may be collected as follows: One end of a piece of 
rubber tubing, two or three feet long and one-eighth or one-quarter 
of an inch in diameter, is introduced to the bottom of the bottle, the 
other end being held in the mouth. A deep breath is then sucked 
through the tube, so that the bottle is completely washed out by the 
surrounding air. The tube is removed while the air is being still sucked 
in, so as to avoid any risk of the breath passing backward into the 
bottle. The stopper is then inserted, turned around, and secured as 
already described, and particulars written on the label. Care must, 
of course, be taken that the sample be not contaminated in any way 
by the presence of persons or lamps." 

The chemists of the New York City Department of Health believe 
that if the sample be analyzed within twenty-four hours no appreciable 
amount of carbon dioxide will be absorbed by moisture. They recom- 
mend the collection of samples in bottles filled with ordinary water 
corked with a rubber stopper, the sample of air being taken simply 
by pouring the water out. 

Determinations of Temperature. — In view of the fact that overheating 
has been clearly shown to be the primary cause of discomfort and injury 
to health in badly ventilated rooms, careful observations of temperature 
are of the greatest importance in studies of air conditions. With the 
exception of the determination of rate of heat loss from a warm, moist 
surface, to be discussed later, temperature records are more significant 
from a hygienic standpoint than any other class of observations. 

Thermometers used for accurate records should be mercury ther- 
mometers with engraved stems and no backings. The total graduation 
range should be from 20° to 120° F., with 1° graduations and no ten 
degrees should occupy a space of less than one-half inch; so that 
accurate readings to within one-half degree may be obtained. Xo part 
of the body of the operator should be within 10 inches of the bulb 
when a reading is taken. 

In addition to observations made at intervals by the use of the 



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badly controlled. 



TESTING OF VENTILATING EQUIPMENT 285 

ordinary thermometer continuous temperature records covering periods 
of several days should be obtained at important points by the instal- 
lation of recording instruments (see Fig. 37). Recording thermometers 
are not very accurate and should be checked daily or oftener by com- 
parison with a standard mercury thermometer, but the picture they 
give of the general variations in temperature during the whole period 
of occupancy is often highly significant. 

The extent of overheating revealed by such studies is sometimes 
astonishing. Thus in one New York office building 34 p«r cent, of all 
observations were between 72° and 75° F., and 9 per cent., 76° and over. 
In a university dining hall 28 per cent, of all observations were between 
71° and 72°, and 16 per cent., 73° and over. On the other hand two 
window-ventilated hospital wards in New Haven showed less than 
5 per cent, of all records over 70°; and a mechanically- ventilated 
school in New York showed only 3 per cent, over 71°. 

Observations made a few years ago by the inspectors of the New 
York State Department of Labor in a series of 215 factory workrooms 
(printing shops, clothing shops, bakeries, pearl button factories, cigar 
factories, laundries and others) gave the results indicated below. All 
these records were taken when the outside temperature was 70° or 
below. 

Temperatures en New York Factories. 

Temperature . . . 72° or less 73° to 79° 80° and over 

Number of workrooms . 59 93 63 

Dr. Helen C. Putnam in a study of 600 schoolrooms reported that 
only 210 had thermometers, only 140 of the thermometers were in 
working order, and of these 140 only 20 recorded temperatures below 72°. 

In the more advanced communities such conditions as these have 
become comparatively rare in recent years. A series of over 1800 
determinations of temperature in Xew York City schools gave the 
following results: 

Distribution of Temperature Records in Xew York 
City Schools. 

Temperature, °F. . . Under 60 60-61 62-63 64-65 66-67 68-69 70-71 72-73 Over 73 
Percentage of total 
records in each class 1 2 4 11 21 27 20 9 5 

Determination of Atmospheric Humidity. — The standard apparatus 
for measuring humidity (ordinarily used for recording temperature 
as well) is the U. S. Weather Bureau Sling Psychrometer. This con- 
sists of a pair of mercury thermometers mounted on a metal back 
which is so jointed to a handle that it can be swung in a half circle. 
One thermometer is of the ordinary type ; the other is a wet-bulb ther- 
mometer, that is its bulb is enclosed in a muslin bag which is moistened 
with distilled water just before the instrument is used. The evaporation 
of moisture from the cloth will of course produce a lowering of tem- 
perature and a consequent depression of the reading of the wet bulb 



286 



AIR AND HEALTH—VENTILATION 



thermometer. The amount of the evaporation and the extent of the 
depression will vary inversely with the amount of moisture already 
present In the atmosphere. From a table like that given on p. 287, it 
is easy from the dry-bulb reading and the difference between the dry 
and wet-bulb readings to compute the relative humidity of the air and 
the actual amount of moisture it contains. 








Fig, 



38. — Types of sling psychrometers for determining temperature and relative 
humidity. 



The sling psychrometer must be. swung slowly back and forth while 
a reading is being taken so as to prevent the accumulation of an 
envelope of moist air in the immediate vicinity of the bulb. The 
process should be continued for several minutes until the wet-bulb 
reading falls no further. Stationary wet and dry bulb thermometers 



TESTING OF VENTILATING EQUIPMENT 



287 



(hygrodeiks) are quite unreliable unless air circulation is secured by 
the use of a fan. 

There are upon the market good recording psychrometers in which 
stationary wet and dry bulbs are played upon by a small fan, the move- 
ment of the mercury or inert gas contained in the bulbs being com- 
municated through a tube to a recording apparatus, the record being 
traced on a paper scale as in the recording thermometer. These are 
valuable for special studies but the variations in humidity are neither 
so rapid nor so important as to call for their use in ordinary studies. 

In certain factories, and at times in auditoria, humidities may be 
found which are excessively high. As a rule, however, the humiditv 




20 25 30 35 40 45 50 65 60 65 70 75 

dry bulb temperature 

Fig. 39 



90 95 100 105 



of occupied spaces in cold weather at least, is too low rather than too 
high, since the warming of the cool outside air increases its avidity for 
moisture, while the actual amount of moisture remains unchanged. 
The actual results of some 1800 determinations in New York City 
schools below give a fair idea of conditions in that latitude. Further 
north, in Montreal for example, the dryness of indoor air in winter 
becomes even more acute. 

Distribution of Humidities in New York City Schoolrooms. 



Relative humidity Under 

percentage of sat- 15 16-20 21-25 

uration 
Percentage of total 

records in each class 6 9 j 14 



Over 
26-30 31-35 36-40 41-45 46-50 51-55 56-60 00 



17 



16 



13 10 



288 



AIR AND HEALTH—VENTILATION 



The Kata Thermometer. — The actual temperature of the air, as has 
been pointed out, is only one factor in determining the effect of atmos- 
pheric conditions upon the temperature of the body. Heat loss from 
the body surface depends upon air humidity and particularly upon air 
movement, as well as upon air temperature. The ordinary mercury 
thermometer is, therefore, a very inadequate measure of the actual 
physiological effect of atmospheric conditions. The condition in a 
close room has been commonly compared with that which obtains out- 
doors on a muggy day in summer ; yet it is a matter of experience that 
the outdoor temperature must be very much higher than the indoor 
temperature in order to produce a comparable degree of discomfort. 




Fig. 40. — The Kata thermometer. (Courtesy, American Public Health Association.) 

Dr. W. Heberden 1 pointed out these facts nearly a hundred years 
ago and suggested a way out of the difficulty by the observation of the 
rate of fall of a thermometer previously heated to a high temperature. 

The same principle has recently been independently applied by Dr. 
Leonard Hill, 2 in England, in the instrument which he' has called the 
Kata thermometer.' 5 

1 An Account of the Heat of July, 1825; together with Some Remarks upon Sensible 
Cold, Trans. Roy. Soc, London, 1826, Part II, p. 69. 

2 The Physiology of the Open-Air Treatment, The Lancet, May 10, 1913, clxxxiv, i, 283. 

3 Sold in United States by H. N. Elmer, 1140 Monadnock Bldg., Chicago (agent for 
Siebe Gorman Company). 



TESTING OF VENTILATING EQUIPMENT 289 

The Kata thermometer outfit as first proposed by Hill consisted of 
two specially constructed thermometers with large bulbs and stems 
graduated from 86° to 110° F., one to be used as a dry and the other 
as a wet bulb thermometer. The bulbs are heated to about 110° and 
then placed in clips which hold them in a horizontal position, after 
drying the bare bulb on a clean cloth and jerking excess moisture off 
the silk covered one. The time taken to fall from 100° to 90° is then 
noted, best by the use of a stop-watch. 

The rate of fall of both thermometers will obviously be affected by 
air movement and radiant heat as well as by air temperature, and that 
of the wet bulb by the humidity of the air as well. Dr. Hill believes 
that the combined influence of these factors will affect the Kata ther- 
mometers very much as it does the human body, and suggests a 45 to 60 
second period for the wet bulb and a 150 to 180 second period for the 
dry bulb as limits for comfortable atmospheric conditions. Recent 
studies 1 have indicated that the lower of the limits set corresponds 
very closely to the average vote of a number of American observers 
as to bodily comfort. 

Hill, Griffith and Flack 2 have recently presented a detailed study of 
the physical problems involved, in which the heat loss from the Kata 
thermometer is calculated in a more exact manner in millicalories per 
square centimeter per second, and the Siebe Gorman Company are 
now putting out instruments whose factors as compared with a labora- 
tory standard have been determined. These new bulbs are graduated 
only from 95° to 100°. The factor divided by the number of seconds it 
takes to make this five-degree drop gives the rate of cooling at body 
temperature in millicalories per square centimeter per second. The 
wet Kata thermometer gives the rate of cooling by radiation, convection 
and evaporation. The dry Kata thermometer gives the rate of cooling 
by radiation and convection. 

This instrument is a distinct improvement over the earlier patterns 
in that results from different instruments are now directly comparable. 

Professor E. B. Phelps, of the United States Public Health Service, 
has devised an instrument based on the same principle, which has the 
great advantage of permitting of continuous records of heat loss. It 
consists of a wet bulb thermometer heated by an electrical coil and 
constant current of such a strength that in a saturated atmosphere 
the thermometer registers 8° higher than an unheated bulb. 

Such instruments as these, which give us information as to the actual 
heat loss from the body surface as a result of the whole complex of 
atmospheric conditions, promise to be of the greatest service in the 
ventilation studies of the future. 

Enumeration of Dust Particles. — The study of the dust content of air 
is of great sanitary moment in connection with certain industrial 
processes in which irritant or poisonous dusts are discharged into the 
atmosphere in considerable amounts. 

1 Winslow, C.-E. A.: The Kata Thermometer as a Measure of the Effect of Atmos- 
pheric Conditions upon Bodily Comfort, Science, N. S., 1916, xliii, 716. 

2 The Measurement of the Rate of Heat Loss at Body Temperature by Convection, 
Radiation and Evaporation, Phil. Trans. Roy. Soc, London, series B, 1916, ccvii, 183. 

19 



290 



AIR AND HEALTH— VENTILATION 



The Palmer Dust Sampler, which seems to be the best form of 
apparatus for this determination, combines the forces of precipitation 
and filtration somewhat on the principle of a commercial air washer. 
The air to be sampled is drawn through water in a shallow trap at 
such a rate as to break the water up into a fine shower of spray in the 
glass bulb above, this spray taking the dust out of the air and finally 
washing it down into the trap. After the completion of a run the dust 
collected in the water may be estimated by any or all of three methods : 
by direct microscopic enumeration in a Sedgwick-Rafter cell, by 
weighing after filtration through a Gooch crucible, or by comparing 
the turbidity of the organized suspension with a set of standards. 

This apparatus (Fig. 41 ) was described w T ith the technic involved in its 
use by Messers. Palmer, Coleman and Ward in the American Journal of 



Fig, 




Palmer water spray apparatus for collecting samples of atmospheric dust. 



Public Health for January, 1916, vol. vi, p. 54, and may be obtained from 
Wallace & Tiernan, of 137 Center Street, New York. The apparatus, 
including the motor and the Venturi meter for measuring the air, may 
conveniently be mounted in a light dress suit case, the whole weighing 
seventeen pounds or less. 

The particles when counted under the microscope should be grouped 
in the following five classes: 

1. Large masses, about 100 standard units (0.04 sq. mm.). 

2. About 25 standard units (0,01 sq. mm.). 



TESTING OF VENTILATING EQUIPMENT 



291 



3. About 1 standard unit (0.0004 sq. mm.). 

4. About J standard unit (0.0001 sq. mm.). 

5. Dust too fine to count — presence indicated by a plus sign. 

A control should always be made, using the same slide and the 
same batch of distilled water, and the average of the five field counts 
obtained subtracted from the average of the ten field counts of the 
suspension of dust. 

The remainder of the suspension should be filtered through a weighed 
Gooch crucible, the crucible and contents dried for one hour at approxi- 
mately 100° C. and weighed to 0.1 mg. 

Enumeration of Bacteria in Air. — The sand filter method, originally 
suggested by Petri, has proved the most satisfactory method for the 





Fig. 42. — Filter for collecting bacteria from air. Ruehle type. 



study of the bacterial content of the air. For the collection of the 
sample the Ruehle tube (Fig. 42) should be used. This is a glass tube 
of 15 mm. in diameter and 70 mm. long with a smaller tube 6 mm. in 
diameter and 40 mm. long fused into one end. On the shoulder at the 
joint between the tubes rests a plug of cotton supporting a layer of 
sand 10 mm. deep. The sand should be capable of passing a 100-mesh 
sieve but not a 200-mesh sieve. The opposite or inlet end of the larger 
tube is stoppered by a cork stopper (which need not be exactly tight) 
perforated by a glass tube 6 mm. in diameter and 40 mm. long bent at 
an angle of 45° to prevent direct precipitation of dust particles into 
the filter tube. 



292 



AIR AND HEALTH— VENTILATION 



Five cubic feet of air should be drawn through the filter by the use 
of an aspirator of known volume, preferably one of the double or 
continuous type, or by the use of some form of pump and meter. 
A convenient and ingenious sampling pump was made by Wallace & 
Tiernan of New York City for the study by Baskerville and Winslow 
of the air pf Xew York City Schools. After filtration the sand should 
be shaken out into 10 c.c. of sterile water, and after thorough shaking 
aliquot portions of the water should be quickly removed and plated on 
ordinary nutrient agar. 

The use of lactose-fermenting streptococci as special indices of 
mouth pollution in the air has been suggested by Gordon; and recent 
studies by Nolte and Winslow and Browne indicate that it may have 
a real value. 1 In case it is desired to make this test the standard 
procedure may be used with the substitution of litmus lactose agar 
for plain agar. Characteristic streptococcus colonies (small, acid colo- 
nies) should be fished to agar and identified by their typical veil-like 
surface growth, microscopic appearance (cocci in pairs or chains) and 
production of acid in lactose broth. A large number of air samples 
must be taken in parallel as these organisms are often found only to 
the number of 10 per 100 cubic feet of air. 

Poured blood agar plates may be used to detect hemolyzing strepto- 
cocci, other streptococci and pneumococci. 



1 Gordon, M. H.: Report on a Bacterial Test for Estimating Pollution of Air, 
Supplement to the XXXII Annual Report of the Local Government Board of Great 
Britain, containing the Report of the Medical Officer for 1902-03, 1904, p. 421. Nolte, 
A. G.: The Identification of the Most Characteristic Salivary Organisms and Its 
Relation to the Pollution of Air, Ann. Missouri Botanical Garden, 1914, i, 47. Winslow, 
C.-E. A., and Browne, W. W. : The Micro bic Content of Indoor and Outdoor Air, 
Monthly Weather Review, 1914, xlii, 452. 



CHAPTER VIII. 

HOUSING. 

By LAWRENCE VEILLER. 

Housing is so vital a factor in public health work that it is strange 
that it has not been given greater attention in recent years in the public 
health movement. This is in striking contrast to the early days of 
that movement in America when the leaders there were also leaders 
in the movement for housing reform. In fact the housing movement 
in America owes its initial impulse to the work of health officers. 

Perhaps one reason for this present situation is to be found in the 
fact that while housing is to a very large extent a health problem, it is 
also an economic problem and a social problem. In times when there 
is a great shortage of houses due to economic reasons it is natural that 
the health aspects of this vital question should be to some extent over- 
looked. There is a small school of sanitarians in America who hold 
that housing is not a health problem and that housing work plays no 
part in the functions of the public health officer. 

We are glad to say that this view is held by only a few persons. 

It is strikingly in contrast with the views of the civilized nations of 
the world. Great Britain, for example, affords a striking illustration 
of the opposite point of view. There the housing problem is a political 
issue and one of the great public questions of the day. 

While the social and economic aspects of the question are there fully 
recognized, its health aspects are considered paramount, as is evidenced 
by the fact that all functions of the Royal Government in relation to 
housing are vested in the Ministry of Health, which is charged with the 
important duty of seeing to it that 500,000 houses of a sanitary and 
modern type are built to meet the needs of the people of England. 

Whatever theoretical views may be held as to whether housing is the 
function of a public health officer or not, the average health officer will 
find in practice that he cannot escape responsibility for it. It is thrust 
upon him whether he wants it or not. It is the wise health officer who 
recognizes this clearly and not only accepts this responsibility, but 
responds to it adequately and enthusiastically. 

Every health officer knows that there is no way by which he can 
escape responsibility for what is known as the usual " nuisance" work, 
a term given not to designate the feeling of the health officer toward it, 
but to describe the class of work involved, namely, work dealing with 
the abatement of nuisances which is the beginning of all health work. 
In truth, the necessity for attention to such matters is what calls into 



294 HOUSING 

being a health department in most communities. Responsibility for 

it can no more be evaded than can responsibility for reducing the 
infant death-rate. 

WHAT HOUSING IS. 

Perhaps one reason for the point of view just discussed — that housing- 
is not part of the work of a health officer — is to be found in the fact that 
the people holding that view have not clearly had in mind how all- 
embracing a subject housing is, and how many of the phases of the 
recognized activities of health departments are included under this 
term. Of the 30 phases of public hygiene discussed in this volume in 
30 different chapters, I note at least 12 of them into which housing 
directly enters as an important factor. It concerns itself vitally with 
the ventilation and heating of buildings, with sewage disposal; with 
infectious diseases; with the relations of insects to human diseases; 
with personal hygiene; with public health education; with water supply; 
with military and camp hygiene and even with personal hygiene. 

Even on its economic side it may have a very important bearing on 
health. Where a serious shortage of houses develops, the resultant 
overcrowding of rooms becomes a most serious factor in the extent and 
spread of such contact diseases as influenza, poliomyelitis and measles. 

The relation of improper housing to health is to be observed in two 
ways — the direct effect and the indirect effect. The latter is to be 
seen in the general lowering of vitality and power of resistance to disease 
of the individual caused by bad living environment. 

TUBERCULOSIS. 

One of the most direct relations between bad housing and disease is 
that between the dark room evil and tuberculosis. 

Though we have known for a quarter of a century the essential facts 
about the control of tuberculosis and its prevention; though we have 
known that a person ill with this disease has practically no chance of 
recovery if living in a dark or badly lighted room; though we know 
that the tuberculosis germ retains vitality for many months in dark 
rooms; though we know the germicidal effect of direct sunlight upon 
such germs in destroying them and making them harmless in a few 
moments, yet the state or city in this country which forbids the erection 
of dwellings with dark rooms in them is the exception rather than the 
rule. 

Literally, one can count on the fingers of one hand the states through- 
out this country which have taken such action. What does this mean? 
It means that we are stupidly today spending vast sums of money — 
millions of dollars — to cure and patch up, so far as we can, the victims 
of this disease which still claims one-tenth of all who die, while at the 
same time we are permitting, without restriction, new conditions to 
be created in every city, town and village throughout the land that 
make success in our efforts to cure these sufferers impossible. We are 



TUBERCULOSIS 295 

deliberately manufacturing— if one may put it that way — new cases of 
the disease literally by the thousands; for, every tenement house and 
common lodging house and dwelling house that is built with rooms that 
are insufficiently lighted is a potent factor in the future development 
and spread of the disease. 

And the reason this situation exists is because the health officers of 
the country have failed in the past to recognize fully their responsibility 
with reference to housing and have been content to leave so trouble- 
some a question as the proper regulation and control of the construction 
of buildings to others. No better illustration could be had to evidence 
the fact that housing is essentially a part of public health work. 

Through the neglect of the health authorities to supervise the con- 
struction of new dwellings and other buildings in which people live, the 
conditions just described have developed. Building inspectors have 
shown conclusively that such questions cannot be safely left to them for 
determination, and it is not strange that this should be so. Why 
should a builder be interested primarily in health matters? And why 
should he be expected to have a knowledge of the close relations that 
exist between insufficiently lighted rooms and the extent and prevalence 
of such diseases as tuberculosis. The average builder is concerned only 
with getting a profit out of the house that he builds, and if he can market 
his house he cares little as to whether it is a healthy house or not. 

We have spoken only of the direct effect of insufficiently lighted 
rooms in their relation to one disease — tuberculosis. The indirect 
effect on health of such conditions is incalculable. Probably no one 
factor will so quickly lower vitality and the power of resistance to 
disease as the constant dwelling in dark or dimly lighted rooms; for, 
darkness is inseparably connected with dirt and disorder. They go 
hand in hand. Where rooms and hallways and cellars and other parts 
of dwellings are dark, conditions of neglect and filth and disorder are 
not so readily visible and therefore are likely to flourish; that dirt is a 
factor in ill health cannot be gainsaid. 

The brilliant and able former Health Officer of the State of Pennsyl- 
vania for so many years, the late Dr. Samuel G. Dixon, fully recognized 
this. In an address delivered not long before his death, entitled 
" Proper Housing Means Cleanliness," he had this to say on this subject: 

" In order to have the abiding places of men healthful, we must have 
them clean — yes, clean hi the broadest sense. We must have clean 
air — that element which affects life more quickly than anything else; 
we must have clean water, which next to air is most necessary to our 
lives; we must also have clean food, clean bodies, clean dress, and clean 
houses, none of which can be maintained without clean air and clean 
water. . . . 

"Housing or the abode of man in its broadest sense cuts a wide 
swath in the field of hygiene. Public and personal hygiene are so 
intimately associated that they are often interlocked so that each 
depends upon the other. . . ." 



296 HOUSING 

VENTILATION. 

Light and ventilation are so commonly associated in the public 
mind that it is a little hard to dissociate them. Whether dark rooms or 
unventilated rooms are the more serious factor in tuberculosis is hard 
to say, for the two are generally interwoven. The room that is insuffi- 
ciently lighted is generally insufficiently ventilated; for, as a rule, it 
means that it has not the proper windows opening on the proper open 
spaces, though there are, of course, cases where artificial ventilation 
is achieved in certain classes of buildings where there is not adequate 
lighting. 

Close, stuffy rooms probably quite as much as darkness, lower the 
power of resistance of the individual and reduce his vitality. In 
summer in warm climates they exercise a most baneful effect. 

Reverting once more to the view that housing is not part of a health 
officers' functions, one cannot help but inquire how a health officer 
is to achieve proper conditions of ventilation if he does not concern 
himself with housing. We have learned in recent years that the three 
great factors in what may be termed proper ventilation are moving 
air, the prevention of too high a temperature and the prevention of 
excessive moisture. 

Just how moving air is to be achieved in the homes where most of us 
spend the greater part of our time — certainly in most cases twelve out of 
the twenty-four hours — if there are no windows in the rooms in which 
we sleep to let in the air, or if the houses or apartments which we 
occupy have been so designed that cross or through, ventilation is 
impossible, is not apparent. Similarly, how we can reduce excessive 
temperature in rooms in the tropical weather which prevails in many 
parts of America in summer time, if there are not windows in our rooms 
to let out the heated air is also a puzzle. It is singular that health 
officers should recognize their responsibilities with reference to the 
ventilation of public buildings and public conveyances such as theaters 
and street cars, as most health officers have come to do, and yet should 
fail to recognize their equal responsibility with reference to the homes 
of the people. 

While the heating of rooms is in no sense so important a question 
as their ventilation, the lack of sufficient heat in our extreme winter 
weather in some parts of the country does become a very serious factor 
in the health of that community; for, where houses are improperly 
heated and the control of the conditions is not within the power of the 
tenant, as is the case in many of our large cities where apartment 
houses and tenements are the rule, then a really "serious situation may 
result; for, nothing will work so great a detriment to a person's power 
of resistance, or will so quickly render one a prey to influenza and 
pneumonia as living in rooms that are insufficiently heated. 

Health officers heretofore have given little or no attention to this 
subject. They have exercised no control over the installation of 
proper heating plants and have only recently commenced to enforce 



PRIVY-VAULTS 297 

ordinances or amend sanitary codes by requiring landlords to maintain 
70 degrees, or some similar standard in winter weather. This is as 
far as they have gone. Even what seems so apparently remote a sub- 
ject as the heating of buildings has come to be an important factor in 
the health of the community. 

ROOM OVERCROWDING. 

No phase of the housing question has so direct a relation to public 
health work as the prevention and control of room overcrowding, and 
no phase of housing has been so generally neglected heretofore in 
this country. Practically no community in the United States has done 
anything effective to control or regulate this serious evil. 

How important it is has been disclosed to the country in the epidemics 
of poliomyelitis and influenza in recent years. Both of these epidemics, 
especially the various influenza epidemics, would have spread to less 
extent had it not been for the crowded conditions of living which pre- 
vail in many of our cities caused by the shortage of housing accommoda- 
tions due to the war. Here the relation between the disease and housing 
conditions is almost in direct arithmetical ratio. It would hardly 
seem necessary to argue that in the control of contact infection people 
should not be allowed to sleep and live four, six or eight in a room and 
that the amount of air space, the frequency of renewal of the air and 
the other factors which enter into adequate ventilation should be 
observed. 

A study made by the Xew York City Health Department in 1916 
of the relations between room density and communicable diseases 
showed this most clearly. 

It was found that where there was less than one person to each room 
the percentage of cases of colds, tuberculosis and other diseases spread 
by contact was 8.18 per 1000 of population; where people were living 
from one to two persons per room the rate of infection was greater, viz., 
8.27 per 1000; where there were two to three persons in a room, it was 
8.62; and where there were three to four in a room it was still greater, 
viz., 9.36 per 1000. 

Just how the school of thinkers who advance the view that housing 
is not a part of public health work believe that health officials can 
control the spread of epidemics like influenza and poliomyelitis and 
measles, if they have no power to reduce room-overcrowding, one is 
puzzled to understand. And if it is not appropriate for the health 
officer to reduce crowding in a room in which people live, why should 
he reduce crowding in a room where people sit to be amused? The 
point of view hardly seems logical, and indeed it isn't. 

PRIVY-VAULTS. 

One of the most serious housing evils that exists in the United States 
today is the existence in very large quantities of the disease-breeding, 



208 HOUSING 

antiquated and obnoxious privy-vault in various forms. No one knows 
just how many vaults there are in the United States, the Federal Health 
Service never having attempted to find out, but that they exist by the 
hundreds of thousands and probably by the millions, there can be no 
doubt. 

In sparsely settled communities where there is no communal w T ater 
supply the privy-vault is, of course, a necessity. In large cities and 
small towns, however, where there is a water supply, the vault is not a 
necessity and should not for a moment be tolerated. 

It still exists in such communities to an unbelievable extent. Less 
than ten years ago an inquiry made in 40 cities showed that in a city 
of 350,000 population there were then 60,000 individual privy-vaults 
and that 50,000 of these were located where sewers were available. 
In another city of 490,000 population it was disclosed that there were 
27,000 privy-vaults of which 20,000 were located where sewers were 
available. 

Before the discovery of the insect as a disease carrier, the privy- vault 
was regarded as a nuisance and something unpleasant because of its 
noisome odors, but since the discovery of the typhoid fly, the privy- 
vault has assumed a different aspect as a potent source of disease. No 
community can hope to rid itself of typhoid fever if it allows privy- 
vaults to exist; for, fly infection is sure to result sooner or later. 

A study of the relation of typhoid fever to the presence or absence 
of sewerage systems* made by the New York State Health Department 
in 1918, and embracing the records of twenty years showed this con- 
clusively. The typhoid death-rate had a 26 per cent, excess in the 
unsewered communities. 

Of the effect of the vault, when present in close proximity to the 
living quarters of the people, in lowering bodily vitality and reducing 
the powder of resistance to disease, it is unnecessary to speak; that it 
plays an important part in this respect is without question. 

Merely connecting existing vaults with sew-ers and thus turning them 
into "school-sinks" as they are called in some parts of the country, 
or "catch-basin privies" as they are called in other parts of the country 
is a makeshift that in no sense solves the problem and an expedient that 
should not be tolerated. The sewer-connected privy is just as danger- 
ous as the ordinary privy with the exception that the element of pollu- 
tion of the water supply, where there are wells, has been eliminated; 
but as privy-vaults can only be sewer-connected where there are 
sew r ers, and sewer systems exist only where there is communal water 
supply this factor is of no moment. 

Every community that calls itself civilized should get rid of its privy- 
vaults in whatever form they exist at the earliest possible moment and 
should insist upon their replacement by modern w T ater-closets located 
inside of the house and properly sew T er-connected. Where there is no 
sewer but a communal w T ater supply exists, it is far better to have 
septic tanks or cesspools constructed and to have the water-closets 
drain into these than it is to continue a system of privy-vaults. 



WATER SUPPLY 299 

Where privies arc necessary in rural communities because of lack of 
water supply, the only type of privy that should be tolerated is the 
modern, sanitary fly-protected one. 

Tf housing is not part of a health officer's work, how is the health 
officer to eliminate malaria by doing away with the places in which 
mosquitoes breed; for, without proper drainage of the surface around 
each house there will be standing pools of water, each one of which will 
be a fertile breeding ground of mosquitoes. The constant inspection 
of rooms and dwellings for the elimination of vermin plays its part in 
the prevention of disease; for, vermin is a carrier of disease, even the 
obnoxious bed-bug playing an important part in spreading disease of 
various kinds. Such things therefore as the elimination of wall paper 
from the homes of the poor and the substitution of sanitary; painted, 
or kalsomined walls is a matter that should concern every health 
officer. Similarly, in large cities where tenement. houses prevail the 
sealing of openings in floors through which steam pipes and plumbing 
pipes pass is essential in order to prevent the passage of vermin from 
floor to floor and from apartment to apartment. 

WATER SUPPLY. 

How great a factor an adequate supply of pure water is in the health 
of the community is so well recognized that it is unnecessary to comment 
on it. Merely ensuring the purity of the source of that supply is not 
sufficient. What is necessary to be done is to make sure that all 
members of the community obtain the use of it freely and easily. It is 
especially important that its use should be made easy to those members 
of the community who are most in need of it, namely, the poor, and no 
obstacle should be placed in the way of their having a generous supply 
at all times. Personal hygiene depends upon it. It is all very well to 
ask people to bathe frequently but if all the water that can be obtained 
has to be drawn from a pump or hydrant in the back yard down three or 
four flights of stairs and then must be carried up those stairs in buckets 
or pails, bathing is not likely to be achieved. So also with cleanliness 
of the home. Where water is obtained with difficulty — and in many of 
our cities this still is the situation — cleanliness of the home is not 
likely to be found and disease is quick to breed in the conditions of dirt 
and filth which result. The health officer therefore, if he wants to 
insure an adequate supply of water to the householder, must concern 
himself with housing and must see to it that all existing houses are 
equipped with running water with sinks or wash bowls, conveniently 
located and easy of access to each tenant, and must also see to it that 
in new houses every family is supplied with its individual water supply. 
In the larger cities where the taller tenements prevail the street pressure 
is sometimes insufficient to cause the wa,ter to rise to the upper stories 
of such buildings. In such cases the health officer will find it necessary 
to compel reluctant landlords to supply pumps or other appliances so 
that the tenants of the upper stories may be provided with an adequate 
water supply. 



:>00 HOUSING 



VENEREAL DISEASE. 



So remote a subject as venereal disease enters into housing; for, one 
of the possible methods by which venereal disease is spread is through 
the common water-closet; most so-called "innocent infections" outside 
of the marriage relation arising in this way. 

More and more clearly the health officers of the country are beginning 
to realize that irrespective of any moral question involved it is their 
function to grapple with the problem of venereal disease as one of the 
serious communicable diseases affecting the health of their community. 

If it is true that the common water-closet with its promiscuous use 
is a factor in spreading venereal disease, then it is clear that the health 
authorities of a community ought to see to it that such conditions are 
not repeated in the future and that new dwellings are not erected in 
which the people who live in them are dependent on the use of a com- 
mon water-closet used by several families. They should also, as rapidly 
as possible, eliminate the existing common water-closets and insist 
upon it that individual water-closets with due privacy are provided for 
every family. 

We have discussed at some length the main factors in the housing 
problem from the point of view of health and have alluded only to 
those that act in a direct and obvious way. There are many other 
factors, however, which enter into the situation which are of greater 
or less importance and which should not be lost sight of. Take for 
instance, such a question as .the providing of individual water-closets 
inside of the apartment, convenient of access to each family in place 
of a privy in the back yard. The effect of toilet accommodations thus 
remotely and inconveniently located is to discourage use. It produced 
therefore bad personal habits resulting in constipation and often in 
appendicitis. Another instance is the effect which stairs that are too 
steep have upon the health of women, especially where women are 
about to be confined. Here again it is evidenced that if the health 
of the community is to be maintained health officers must exercise 
control over buildings in many respects. 



THE PLACE OF HOUSING IN HEALTH DEPARTMENT 
ORGANIZATION. 

We have seen from what has been said that housing does vitally 
concern the health officer and does play an important part in his work. 
Let us consider now, briefly, the place that it should occupy in the 
proper organization of a health department. The defects of the present 
methods of health organization from the point of view of housing are : 

1. The average health officer has little knowledge of the sanitary 
evils that exist until his attention is called to them by the complaint 
of some citizen. In most communities inspection of dwellings and the 
surrounding out-premises is made solely on complaint. There is no 



HEALTH DEPARTMENT ORGANIZATION 301 

adequate system of complete sanitary inspection at regularly stated 
periodic intervals for the purpose of discovering sanitary evils and 
remedying them promptly. Such a system of periodic sanitary patrol 
is the only system of sanitary inspection that is worthy of the name of 
system. The present unfortunate methods which are a relic of earlier 
and simpler days, mean that frequently the most serious sanitary evils 
are overlooked and neglected while attention is given to some trivial 
matter because of the insistence of the citizen complaining. 

2. Another serious defect of the present scheme of organization is to 
be found in the lack of knowledge which the health officer has of the 
continuing history of the buildings in his community that are in them- 
selves dangerous or detrimental to health. Few health departments' 
record systems are so organized that the health officer can tell at a 
moment's notice the complete history of any particular building in 
that city from the point of view of health. He should be able to do so. 
He should not only be able to know upon inquiry how many cases of 
typhoid, of tuberculosis, of diptheria, of scarlet fever have come from 
a given building, but he should have his records so organized and his 
system so perfected that by a system of signals, whenever there is an 
undue amount of disease in any building, this fact will automatically 
be called to his attention so that the building may be made the subject 
of special study to determine the reasons for the conditions and to take 
steps to remedy them. 

3. Every modernly organized health department recognizes that the 
pulse of the organization is its Bureau of Records. Such a bureau 
should contain in card form two main classes of records, one class giving 
the health and disease record of every building in that community; 
the other giving the health and disease record of every person in that 
community, starting before birth, where possible. Some cities are 
beginning to do this; for, with the prenatal Work that is now becoming 
so important a factor in reducing infant mortality, records are being 
obtained of the child before it is born and the child's history is being 
carried through from early infancy through its school period and ulti- 
mately on into adult life. No health department can consider itself 
properly equipped that does not have a central bureau of records con- 
taining in card form these two broad classes of information. 

4. Another defect of our present methods of health department 
organization, from the point of view of housing, is to be found in the 
fact that, because of the usual absence of proper records, the health 
officer does not know where the places are that need his greatest 
attention. He is therefore unable to concentrate his attention upon the 
places that need it most. As a result the whole city is divided up into 
geographical districts and all districts are treated alike. This is a 
serious economic waste and with the limited resources and equipment 
which most health departments are working with, one of the reasons 
why more is not accomplished in reducing death-rates and preventing 
disease. What a futile waste of time it is to send visiting nurses to the 
homes of the average citizen who, as a rule, needs no such visitation, 



302 HOUSING 

when three blocks away families are suffering for lack of it and the 
health of the community is being endangered thereby. 

In cities of vast size where the poorer districts are clearly differen- 
tiated from those where the mechanics and better paid artisans dwell, 
this difficulty is not so keenly felt, for it is possible there to concentrate 
activity upon a fairly well defined area; but in the average community 
such clearly differentiated districts do not exist, and it is of very great 
importance for the health officer to know accurately the individual 
houses and families that most need his attention so that he may give 
it to them. 

5. The average health officer is still in most cities without adequate 
legal powers. In most communities his legal powers are limited to the 
abatement of nuisances, but if he is to cope with housing evils his 
powers must go much further than this. He must have the power to 
vacate a building where it is in a condition that is dangerous or detri- 
mental to health and such power must be a summary one — one that he 
can exercise, if necessary, on twenty-four hours notice without the 
necessity of application to the courts with the possibility of long legal 
delays. He must have the power to stop the erection of a new building 
that is fundamentally violating sanitary requirements. He must be 
free to go in, if necessary, and hire workmen and do the work through 
his own agents if necessary to remove unsanitary conditions. Where, 
for instance, some foul privy exists and the owner is unwilling to 
remove it, the health officer should be free to hire workingmen and 
remove the privy himself, charging up the expense of such work 
against the property. The power to imprison, after conviction of 
course, violators of the health laws should be given everywhere. In 
many communities the health officers' power is limited to the imposing 
of small fines or the collection of small penalties through the minor 
courts. Every health officer should have available the services of a 
competent legal adviser devoting the greater part of his time to the 
prosecution of the health departments' work. 

6. Finally, if the city is to be made a healthy city, the health officer 
must be able to prevent the creation in new buildings of sanitary evils. 
This means that he must have control over the plans of all new dwell- 
ings, in fact he should have such control over the plans of all new 
buildings, for buildings other than dwellings, work shops, theaters, 
office buildings are vitally concerned with questions of health. 

We have said that an efficiently organized health department should 
ultimately have a complete record of every person, starting before 
birth where possible. We are tempted to say that a health depart- 
ment should have the records "before birth' also of every building. 
The time to correct defects in buildings, from the sanitary point of 
view, is when the plans are made and before the buildings are erected, 
not after they are up. Then, as a rule, it is too late. It should not 
be possible in any city to erect a new building until the plans for that 
building have had careful examination by the health department and 
had the approval of the health officer. 



HEALTH DEPARTMENT ORGANIZATION 303 

The cities where this is the practice today are the exception rather 
than the rule and such an important change in procedure will encounter 
strenuous opposition from building interests and building inspectors. 

That this view has excellent authority behind it is to be found in the 
fact that it is held by such men as Dr. George B. Young, for a number 
of years Health Commissioner of the city of Chicago and a member of 
the U. S. Public Health Service. In a report on conditions in Charlotte, 
X. C, in 1917, he says: 

" Building inspection has hitherto been almost wholly concerned with 
provisions for securing structural integrity. The questions of light, 
air space, ventilation and sanitary construction have had scant atten- 
tion, although much the most important. A few people may suffer 
if a roof sags; thousands suffer daily from bad ventilation. The build- 
ing inspection should be a part of the Health Department, or at the 
very least that Department should have an effective part in building 
regulation." 

This is but a forerunner of a broader conception of public health 
activities and of the functions of health departments expressed by 
Assistant Surgeon General W. S. Rucker of the U. S. Public Health 
Service. As recently as 1917, in an article entitled "A Program of 
Public Health for Cities," he says: 

". . . Health departments, for the most part, operate in end- 
results. Under the present system disease must appear before it can 
be attacked, the municipal policy being one of eradication rather than 
prevention. This is to be expected in cities which maintain fire 
departments for the purpose of extinguishing fires rather than to pre- 
vent them, and under this system it would be more logical to call the 
health department the disease department. . . ." 

". . . The essential element in a public health program for 
cities is a definite public health policy which shall bring the health 
agency into close touch with every activity of communal existence. 
Xot a policy which endeavors alone to prevent those diseases which are 
caused by vegetable and animal parasites, but one which aims at the 
control of that greater body of destructive agencies, human parasites. 
Xot a policy which tries to control the insanitary tenement yet leaves 
out of consideration the cupidity which fixes its rent, but a public health 
policy which shall embrace the entire political economy of disease, a 
policy which shall be as broad and far reaching as human nature, since 
after all, human nature is the groundwork from which arises the fabric 
of the public health." 

Surgeon-General Rucker even goes so far as to hold that no legisla- 
tion should be enacted by the city council without the advice of its 
health department. He says: 

". . . Xo legislation should be enacted by the city council 
without the advice of its health coordinating focus. To it the execu- 
tive branches of the city government should refer all plans and matters 
of policy in order that all may be integrated for health. The direct and 
indirect authority vested in this office is great and far-reaching. . . ." 



304 HOUSING 

"Since concentration is inversely as the transportation facilities, 
the health department should be the first to be consulted in any plans 
for the increase of rapid transit. All of the problems connected with 
streets, with housing, industrial conditions, playgrounds, parks, schools, 
all of these bear an intimate relation to health and as such should come 
within the purview of the health commissioner. . . ." 

ENVIRONMENT AS A FACTOR. 

Thus far we have discussed what may be termed the more direct and 
obvious relations between bad housing and disease and lowered physical 
condition. 

There is a larger aspect to the question than this. It is the whole 
broad question of proper environment; of the influence on morale; of 
the power of resistance to disease; of the mental and physical equip- 
ment of the individual; of the effect of living a drab and sombre exis- 
tence in sordid surroundings. When one's physical outlook on life is 
on some filthy alley, piled high with the castoff refuse of humanity, 
noisome with odors, and when as far as the eye can reach there is noth- 
ing but sordid stretches of drab unpainted, dilapidated uninteresting 
buildings — one vast waste space, it is not strange that one's mental 
outlook on life should be very much the same. How we can expect 
either a healthy body or a healthy mind in people who have that kind 
of environment day in and day out is beyond understanding. 

That the providing of the right kind of environment can materially 
change the health of a community has been proved in most striking 
fashion in recent years by the Garden City and Garden Village develop- 
ments of England. Some years ago a soap manufacturer, William 
Lever, wishing to obtain a contented and stable labor supply for his 
soap factory located on the outskirts of Liverpool determined to build 
a model community in which his workers might live, each family in its 
own individual house with sunshine and fresh air on all sides of it; 
with trees and grass and gardens; with opportunities for rational 
social life and recreation, both for child and man. Actuated by this 
conception there was established the famous village of Port Sunlight 
on the outskirts of Liverpool, the precursor of the later Garden City 
and Garden Village developments of England. Port Sunlight, which 
drew its population from the poor quarters of the neighboring city of 
Liverpool, has now been operating long enough to enable one to 
measure the results of this kind of environment. In George Cadbury's 
book on "City Planning" some striking figures are presented showing 
the effect of such environment upon the children in Port Sunlight 
and in Mr. Cadbury's own similar village of Bournville as contrasted 
with the. neighboring city of Birmingham. 

In a careful study of conditions children were taken at different age 
periods and weighed and measured, boys separately from girls, and all 
taken from the same social status or rank in the industrial community. 
It was shown from this study that boys of 6 years of age from the 



ENVIRONMENT AS A FACTOR 



305 



Garden Village of Bournville weighed 45 pounds as contrasted with 
39 pounds, the weight of the boys coming from St. Bartholomew's 
Ward of the neighboring city of Birmingham, only twenty minutes 
away. At 8 years the Bournville boys weighed 52.9 pounds as com- 
pared with 47.8 pounds in Birmingham. At 10 years of age Garden 
Village boys weighed 61.6 pounds as compared with 56.1 pounds in 
Birmingham, and at 12 years of age the Garden Village boys weighed 
71.8 pounds as contrasted with 63.2 pounds in Birmingham. Similar 
variations were found with the weight of the girls. For example, the 
Garden Village girls of 8 years of age weighed 50.3 pounds as compared 
with 45.6 pounds in Birmingham. 

Similar measurements as to height showed similar results. Garden 
Village boys from Bournville at 6 years of age measured 44.1 inches 
as contrasted with the Birmingham boys of that age who measured 
but 41.9 inches. Eight -year-old boys of the Garden Village measured 
48.3 inches compared with a height of 46.2 inches for the Birmingham 
boys, and so it went through all other age periods. Similar facts were 
disclosed with reference to the girls. 

The following statement in tabular form shows the above facts in 
detail : 



WEIGHT. 



Boys — Bournville (Garden Village) 

Boys — St. Bartholomew's Ward, Birmingham 

Girls — Bournville (Garden Village) 

Girls — St. Bartholomew's Ward, Birmingham 



Age 6 

years. 
Pounds. 

45.0 
39.0 
43.5 
39.4 



Age 8 

years. 

Pounds. 

52.9 
47.8 
50.3 
45.6 



Age 10 

years. 
Pounds. 

61.6 
56.1 
62.1 
53.9 



Age 12 

years. 

Pounds. 

71.8 
63.2 
74.7 
65.7 



HEIGHT. 

Boys — Bournville (Garden Village) 

Boys — St. Bartholomew's Ward, Birmingham 

Girls — Bournville (Garden Village) 

Girls — St. Bartholomew's Ward, Birmingham 



Inches. Inches. Inches. Inches. 

44.1 48.3 51.9 54.8 
41.9 46.2 49.6 52.3 

44.2 48.6 52.1 56.0 
41.7 44.8 48.1 53.1 



DEATH-RATES. 

Infantile death- Ordinary death- 

rate per 1000 rate per 1000 

births. births. 

Bournville (Garden Village) 55.0 4.8 

Letchworth (Garden City) 50.6 6.1 

Hampstead (Garden Suburb) 62.0 9.8 

Bournemouth 7 °.0 9 - 9 

Lewisham 62.0 10.4 

Hammersmith 90.0 13.1 

London 101-0 13.6 

When it came to death-rates similar striking statistics are shown. 
The infantile death-rate per 1000 births in the Garden Village of 
Bournville was 55.0 as compared with 101.0 in London, and the general 
death-rate per one thousand births in the Garden Village of Bournville 
was reduced to the amazingly small rate of 4.8 contrasted with the 
death-rate then prevailing in London of 13.6. Some years later there 
20 



30G HOUSING 

was established that extraordinary community known as the First 
Garden City located at Letchworth, England, where not only the ideal 
conditions of living which have been described as prevailing at Port 
Sunlight and Bournville are to be found, but in addition a self-contained 
community was established with sufficient industries to support the 
members of that community. Letchworth has now been established 
long enough to make similar statistics available. I need refer to only 
one statement to show what extraordinary results have been achieved. 
It is this : 

"The infant mortality figures for 1917 show the death-rate in Letch- 
worth to have been 36 to the thousand, while in 96 large urban centers 
it was 104 to the thousand." 

So much for the infant death-rate. When the general death-rate 
in London was 13.6, the general death-rate in Letchworth was only 6.1. 
One might go on almost indefinitely adducing similar facts. 

HOW TO ACHIEVE GOOD HOUSING. 

If housing plays so important a part in public hygiene and in the 
work of the health officer, it may be asked "How are good housing con- 
ditions to be achieved?" There are two methods. The chief one is — 

1. By Legislation and Law Enforcement. 
The second one is — 

2. By Public Education and by Holding up the Right Standards. 
Health officers and public-spirited citizens interested in the health 

of the community should seek the enactment of housing legislation 1 . 
By that is meant laws, and preferably State laws rather than local 
ordinances, which will insure that all future dwellings erected in that 
community shall be fit places to live in; that there shall be no dark 
rooms in them; that rooms and halls shall be not only well lighted and 
ventilated but shall secure as much direct sunshine as possible; that 
there be convenient and adequate water supply, proper methods of 
waste disposal; that rooms shall be of adequate size; that buildings of 
undue height shall be forbidden; that buildings shall not be crowded 
too close to each other; that foul and filthy outpremises shall be done 
away with; that dangerous and disease-breeding privy vaults shall be 
eliminated — in a word, that the homes and dwelling places of the people 
shall be safe and sanitary and these conditions shall apply not only to 
the dwellings that may be erected in future, but shall, so far as prac- 
ticable, be made to apply to all of the existing dwellings in that com- 
munity. It must, however, be a housing law and must apply to all 
buildings in which people live, to hotels and lodging houses, boarding 
houses and rooming houses, clubs, asylums, hospitals and even jails. 

1 Health officers will find in "A Model Housing Law," revised edition 1920, Russell 
Sage Foundation, 130 East 22d Street, New York City, a ready-made housing law 
which can be easily adapted to suit local conditions. They will also find that this 
book serves as a set of standards us to the conditions that should prevail in their com- 
munity. 



HOW TO ACHIEVE GOOD HOUSING 307 

It must provide for the supervision of all dwellings by the health 
authorities at reasonably frequent intervals. It must contemplate 
compulsory alteration of the older houses where necessary and where 
practicable. 

The other method by which good housing conditions can be achieved 
is through public education; by holding up the right standards to the 
community. Bad conditions which prevail in so many of our cities 
today are due largely to the fact that people have not had proper 
standards. They have been due to ignorance and neglect much more 
than to greed. How many builders realize the fundamental principles 
of ventilation or sanitation? How many architects even have kept 
themselves in touch with the latest and most modern developments in 
that science? We can confidently say very few. By holding up to 
the men who are responsible for the creation of buildings the right 
standards; by impressing not only upon the architect and builder, but 
upon investors and upon the financial interests in the community that 
finance the production of buildings what the right standards are that 
should prevail, the health officer can accomplish much; even more, 
perhaps, by bringing home to the entire community the importance of 
such standards so that the day may come when people will no longer 
be content to live in the dreary monotony of the average city street, but 
will insist upon a wholesome and attractive environment; will demand 
that the places where they live shall be like Letchworth — with its death- 
rate of 6 to the thousand, and not 14 to the thousand as in most cities. 

That housing presents many difficulties will be no discouragement 
to the progressive and intelligent health officer; for, it is the difficult 
tasks that are the most interesting ones. 

Nor should a courageous health officer be deterred by the fear of the 
opposition that he will encounter from interested property owners. 
That such opposition will be encountered there can be no doubt, but 
the health officer should approach his task bearing in mind the words of 
ElihuRoot: 

"There never was a reform in administration in this world which 
did not have to make its way against the strong feeling of good honest 
men, concerned in existing methods of administration, and who saw 
nothing wrong. It is no impeachment of a man's honesty, his integrity, 
that he thinks the methods that he is familiar with and in which he is 
engaged, are all right. But you cannot make any improvement in this 
world without overriding the satisfaction that men have in things as 
they are, and of which they are a contented and successful part." 



CHAPTER IX. 
FOOD. 
By EDWARD K. DUNHAM, M.D. 

There are several ways in which food is important to health. It is 
self-evident that it should be wholesome in quality, suitably prepared 
and in adequate quantity and variety to meet the needs of the individual 
consumer. While some of these requirements are not easily defined 
in an accurate way, knowledge of these matters has made very con- 
siderable advances within recent years. 

The decision of some of the questions which arise in connection with 
the choice and quantities of food consumed must rest with the indi- 
vidual. It is not unimportant that his taste should be gratified in his 
selection of dishes, provided that taste has not been vitiated by unwise 
habits or indulgences. The distribution of the daily ration among 
meals differing in abundance and character will also depend upon 
individual preferences, experience and convenience. 

There are other matters, at least in cities, which are beyond the con- 
trol of individuals. These are properly cared for by municipal, State 
or Federal authorities, and the legal regulations within this field have 
been greatly extended during the past generation. 

Because in some respects they are the clearest and most definite, it 
is well to consider first certain quantitative needs of the human being 
for food. These rest upon the demands entailed by growth, the main- 
tenance of body structures and the amount of energy expended in the 
total activities of the individual. 

Food, the Source of Bodily Energy. — In the common affairs of daily 
life, when there is need of either heat or power, recourse is had to the 
burning of some form of fuel. The chief chemical elements concerned 
in the combustion of commercial fuels are carbon and hydrogen, 
whether coal, wood, or any other fuel is the one employed. 

Within the body similar processes of combustion or oxidation 
liberate heat or other forms of kinetic energy which are utilized to 
maintain the activities of life. The fuel elements are the same, being 
the carbon and hydrogen entering into the composition of foods and 
the end-products, when oxidation is carried to completion are in all 
cases carbon dioxide and water. 

Since the energy required by the body is derived. from food constit- 
uents by chemical cleavages in which oxidation plays a prominent 
part, a study of foods would manifestly be incomplete without a 
consideration of their fuel or "calorific" values. 

The Heat Unit or "Calory." — In discussions involving quantitative 
relationships, it is necessary to select some applicable and convenient 



FOODSTUFFS AS FUEL 309 

unit of measurement in which the quantities under consideration can 
be expressed. All forms of energy can be expressed in terms of heat, 
for they can all be transformed into this particular manifestation of 
energy, and this is a convenient form for measurement in studies of 
metabolism. The unit of heat is the calory, defined as the amount of 
heat required to raise the temperature of one liter (kilogram) of water 
one degree centigrade. 1 The mechanical equivalent of this unit is 
423.985 kilogram-meters, or, approximately, 3063 foot-pounds. A 
further conception of the magnitude of this unit may be gained from 
the knowledge that 12.5 grams of carbon or 3.4 grams (38 liters) of 
hydrogen yield 100 calories when burned, and this is the case whether 
the combustion be rapid or slow, though the temperature at which the 
oxidation takes place will vary. This amount of energy, could it be 
applied without loss, would suffice to raise 15 tons one foot, or nearly 
6 pounds a height of a mile. 

Foodstuffs as Fuel. — Proteins, carbohydrates and fats all contain 
both carbon and hydrogen and, in consequence, are sources of energy 
when consumed in the body. But the proteins are not so completely 
burned as the other two classes of foodstuffs, since the end-products 
of nitrogenous metabolism contain carbon and hydrogen which have 
not undergone complete oxidation. A distinction may therefore be 
drawn between proteins on the one hand and carbohydrates and fats 
on the other; the latter being regarded as primarily fuel foods, while 
the proteins are of essential value in tissue production and maintenance, 
being the source of the amino-acids entering into the composition of 
the body proteins. 

Isolated carbohydrates and fats contain only carbon, hydrogen and 
oxygen. Of the two groups, the carbohydrates contain more oxygen 
(53.33 per cent.) than the fats (10.75 per cent, to 12 per cent.) and are 
therefore less rich in the fuel elements. 

While there are variations within each of the three groups of food- 
stuffs, as a basis for calculations the calorific values may be taken at: 
for one gram of protein or carbohydrate, 4.1 calories; for one gram of 
fat, 9.3 calories. These figures apply only to the purified food con- 
stituents of each class when free of water. 

With perhaps the single exception of refined sugar, foodstuffs are 
not commonly available in such isolation. Practically all the natural 
foods ot daily life are mixtures of the three classes of foodstuffs in vari- 
ous proportions. Nevertheless it is possible to calculate the fuel value 
of a given natural food without recourse to a complete separation and 
determination of these constituents. Considering the complexity of 
their composition, comparatively few data are required as a basis for 
calculating the combined fuel values of the constituents with sufficient 
accuracy for dietary purposes. 

The important analytical determinations are: 

1. Water; the percentage loss of weight on complete drying at 105 
to 110 centigrade. 

1 This is the "large calory" which is 1000 "small calories," the heat required to raise 
the temperature of one gram of water one degree centigrade. 



310 FOOD 

2. Fat; the weight of an ether-extract from the dried substance, 

calculated as percentage of the original sample. 

i5. Nitrogen; usually determined by the Kjeldahl method. 

4. Ash. 

f). Carbohydrates; determined by the hydrolytic conversion of 
starches into sugar and estimating these through the reduction of cop- 
per salts. But in many cases the carbohydrates may be estimated 
by difference with sufficient accuracy for ordinary needs. 

The protein content of the food is taken as 6.25 times the nitrogen. 

In using data obtained in this way for calculating the calorific value 
of a natural food, an allowance is made for inaccuracies due to ignor- 
ing indigestible ingredients and including nitrogenous substances not 
protein in nature with those that are protein. These allowances lead, 
in practice, to the use of the following factors: 1 gram of protein or 
carbohydrate, 4 calories; 1 gram of fat, 8.9 calories. 

CALCULATION OF FUEL VALUE AND COST BASED ON AN ANALYSIS. 



Water 


25.08 






Protein 


10.95 


(N = 1.752) . . 


. x 4.0 = 43.80 calories 


Fats . . . 


.853 




. x 8.9 = 7.59 " 


Ash . . . 


1.635 






Carbohydrates 


61.482 


(by difference) 
100 gm. bread . 


. x 4.0 - 245.93 " 




100.000 


. . . . 297.32 " 



Average weight of a loaf, 355 grams; maximum, 370; minimum, 345. 
Cost, 5 cents. Total calories in average loaf, 1055 (2.97.32 X 3.55). 
Cut into 20 slices J inch thick, each slice would be equivalent to 52.25 
calories at a cost of J cent. 

One hundred calories = 33.63 grams of bread (100 -v- 2.9732), 
costing 0.474 cents. 

Directing attention to the protein, the whole loaf contains the fuel 
equivalent of 155.49 calories (43.8 X 3.55) and to obtain 100 calories 
from this constituent 228.3 grams of bread must be consumed; over 
half a pound and nearly two-thirds of the whole loaf, at a cost a little 
over 3.21 cents, which, however, would also include 578.8 calories 
derived chiefly from carbohydrates. 

Nutrient and Fuel Needs of the Body. — It is convenient to make a 
distinction between those foods which furnish materials essential to 
maintain the structure of the body, those which are predominatingly 
sources of energy and those which serve as adjuncts of importance in 
conserving health. For the sake of brevity, these may be designated 
as "nutrient," "fuel," and "supplemental" groups. 

The nutrient group of foods is made up chiefly of proteins. These 
differ to some extent in the variety and relative proportions of the 
amino-acids they contain, as well as in other respects. The proteins 
of animal origin, meat, fish, eggs, milk and its products, are somewhat 
preferable for human consumption than are the vegetable proteins, 
but the differences are not very great and a relatively small proportion 
of the better proteins suffices to correct any deficiencies in those derived 
from the vegetable kingdom. When estimated in calories, about 10 



NUTRIENT AXD FUEL XEEDS OF THE BODY 



311 



per cent, of the total food intake should be protein. People habitually 
consume considerably more than this and growing children actually 
require a larger proportional amount to encourage development. 

The fuel group of foods is made up chiefly of carbohydrates and fats, 
although proteins have a fuel value equal to that of carbohydrates. 
About 90 per cent, of the total calories per diem may be drawn from 
this group; 30 per cent, fat and 60 per cent, carbohydrate making a 
reasonable distribution between the two members. 

In the supplemental group of foods may be included those which 
are of value because of inorganic or indigestible constituents and the 
various condiments that stimulate the appetite and promote digestion. 

In estimating the amount of food required daily by an individual, 
the greatest precision is attained by employing measurements in terms 
of calories. Bearing in mind that the fuel elements in the food are the 
source of energy, whether this appears primarily as heat or is first 
manifested in muscular activity, it is obvious that the needs of the 
body will be governed by a number of circumstances and that it is not 
possible to fix upon invariable figures expressing the needful number of 
calories for each day. Exposure to cold, particularly when the heat- 
absorbing capacity of the surrounding air is augmented by humidity, 
is an important factor raising the demand for fuel. The intensity and 
duration of manual labor is the other chief factor which is subject to 
wide variations. 

The minimal need of an adult in complete repose and well protected 
by warm covering in bed is from 1500 to 1700 calories. Sedentary 
occupations with moderate exercise raise the amount to about 2500 
calories, and heavy manual labor increases the total to from 3000 to 4000 
calories. The average need for farmers is placed at 3500, and this is a 
fair allowance for mechanics not engaged in unusually continuous and 
severe muscular effort, such as blacksmithing, wood-sawing, etc. 

As a rule, women require about 10 per cent, less fuel than men, but 
this is probably due to differences in size and occupation between the 
sexes. The loss of heat is proportional to the superficial area of the 
body, large people requiring more fuel to maintain a normal tempera- 
ture than small people. 1 

A newborn infant, weighing 8 pounds, requires approximately 370 
calories per day; a child of ten years about 1500. School boys parti- 
cipating in winter sports while lightly clad and therefore exposed to cold 
during periods of great muscular activity require almost 5000 calories, 
an amount demanded by few occupations in adult life, and the appetite 
of the school boy is correspondingly phenomenal. 

On the basis of 2500 calories per day, these might be distributed 
among the foodstuffs as follows: 

10 per cent, protein .... 250 calories, approximately 62 grams ( 2.2oz.) 

30 per cent, fat 750 " 82 " ( 2.9 oz.) 

60 per cent, carbohydrates . . 1500 " " 375 " (13.3 oz.) 

100 per cent. 2500 

1 The area of the body may be calculated with reasonable accuracy from the weight 
and height of the individual by Meeh's formula : A = V w X Vh X 167 . 2 in which A = 
area in square meters, w = weight in kilograms and h = height in centimeters. 



312 FOOD 

These figures cannot be applied directly to the selection of natural 
foods, since very few of these belong exclusively to one class of food- 
stuff. Meats contain not only protein, but also varying quantities of 
fat. And most carbohydrates and animal fats contain protein. In 
calculations concerning a dietary, these complexities in the compo- 
sition of natural foods should be considered. Examples of such calcu- 
lations applied to recipes and meals are given below. For infant 
feeding these conceptions have been familiarized in the formulae for 
the modification of cow's milk. Similar methods may be made appli- 
cable to the more varied dishes of any menu. 

Another obstacle lies in the fact that a third measure of quantity, 
the calory, is introduced into the calculations. Few people have 
habituated themselves to estimate amounts of food in terms of calories 
although this is the most direct and convenient way of making the 
provision of food conform to the needs of the body. 

The sources of information that would encourage thought in this 
direction have not until recently been brought to popular attention 
in tangible form. The prices of food products in this country have 
generally been on a comparatively low level and the need of economy 
has not been urgent. But since the beginning of the war patriotic 
motives and the necessity for saving have made such economies a 
matter of importance. The public press has contained many articles 
on food values and market prices and called attention to ways in 
which saving could be effected and a few restaurants have placed upon 
the bills of fare the estimated calorific values of the portions served. 

This is such an important educational movement that a brief 
abstract of such a menu is given. The figures in parenthesis indicate 
the calorific value of an average portion: 

Cents. 

(170-250) Toast, dry or buttered 10 

( 289) Milk toast 20 

( 18) Coffee 05 

( 60) Coffee with cream 10 

( 195) Milk per glass 10 

( 18) Tea, per pot 10 

( 150) Hot chocolate 10 

( 270) Rice with butter 10 

( 300) Rice with milk 15 

( 300) Crackers with milk 15 

( 250) Flaked cereals with milk 15 

( 216) Shredded wheat with milk 15 

( 140) Minced ham sandwich 10 

( 130) Ham sandwich 10 

( 140) Oyster sandwich 10 

( 200) Fried egg sandwich 15 

( 180) Sliced chicken sandwich 20 

( 430) Club sandwich 50 

( 460) Corned beef hash 25 

( 600) Broiled lamb chop 30 

( 340) Plain omelet 30 

( 390) Onion omelet 35 

' ( 530) Ham omelet 35 

( 470) Hamburger steak 40 

( 600) Fried or broiled ham 40 

( 720) Broiled bacon 40 

( 680) Bacon and eggs 50 



NUTRIENT AND FUEL NEEDS OF THE BODY 313 

Cents. 

650) Ham and egg* 50 

250) Potatoes 10 

220) Carrots . 10 

90) Turnips 10 

65) String beans 10 

160) Onions 10 

30) Cabbage 10 

65) Beets * .... 10 

200) Vegetable soup 10 

210) Chicken soup with rice 15 

315) Baked spaghetti with cheese 15 

460) Baked beans 15 

456) Baked beans with pork 20 

450) Beef stew with vegetables 30 

524) Sausage with potatoes 35 

515) Cold ham, potato salad 35 

292) Wheat Cakes with Syrup 15 

375) Cornmeal Cakes with Syrup 15 

140) Stewed apricots 10 

150) Cruller 05 

90) Fresh apple sauce 10 

270) Layer cake 10 

150) Stewed prunes 10 

265) Creamed tapioca pudding 10 

340) Pie 10 

220) Cup custard .15 

The prices are those of February 3, 1919. 

The single calory is too small an amount to be useful in appraising 
fuel values for domestic purposes. It is, however, an interesting 
coincidence that so many familiar articles of food are equivalent to 
100 calories. One ounce of most cereals closely approximates this 
value, so does a shredded wheat biscuit the average weight of which 
is a trifle under one ounce. A yellow banana, somewhat above the 
average size, a large apple or orange, a Bermuda onion, a potato about 
the size of a woman's fist, all have values not far from 100 calories. 

The accompanying photographs in which amounts of uncooked 
food equivalent to 100 calories are compared with the capacity of an 
ordinary tumbler or the size of a Swedish match-box or butter-plate 
will help to fix in mind this 100 calory quantity. 

Food Economics. — There are difficulties to be overcome in putting 
methods of this sort into practice. Among these difficulties is the 
translation of measures by volume into their equivalents in weight. 
The available scientific data concerning food values are expressed in 
terms of weight, the metric system being most usually employed. 
The recipes for domestic dishes are most frequently given in terms of 
ill-defined measures of volume, such as the "cup, tablespoon," etc. 
This implies a latitude in the use of recipes allowing for the exercise 
of the taste and skill which constitute the Culinary Art. But such 
domestic habits offer obstacles to the precise application of scientific 
methods to household economics and have a tendency to discourage 
such attempts. 

A certain amount of arithmetical calculation is unavoidable in 
making a practical application of fuel values to household economics 
because the market prices of food supplies vary with the season of the 



314 



FOOD 




I 12 ,7 13 14 15 16 




18 19 1 20 Z\ ZZ 




Fig. 43. — Photographs of one hundred calory portions. 



FOOD ECONOMICS 315 

year and local conditions. The recipes used in preparing dishes are 
almost legion and are modified according to the taste and skill of those 
in the kitchen as well as the desires in the home and for this reason a 
standardization of recipes for household use would be impracticable. 

To render the application of arithmetic to this economic problem 
as simple as possible, the following table has been prepared as an 
example of the way in which certain basic calculations can be made 
once for all, yielding factors for use with the market prices prevailing 
at the time. 

In this table the average weight of a "cup" is given in grams, 
following this is the fuel value of that amount expressed in calories. 
The next two columns give the cost-factors of a "cup" and a portion 
of 100 calories, respectively. By multiplying the price per pound of 
the commodity by the appropriate factor, the cost of a "cup" or of a 
portion (100 calories) can be calculated. 

AYith the aid of an extended table of this sort, it is possible to esti- 
mate the cost in materials of a recipe and its fuel value. The economy 
that could be effected by substituting, for example, one cereal for an- 
other or oil for butter can also be ascertained by comparing the costs 
per 100 calories; thus discovering a means of maintaining the fuel 
value while reducing the total expense. 1 

Eggs have not been included in the table because they are not 
usually sold by weight. The fuel value of the average egg may be taken 
at 74 calories; the white at 16 and the yolk at 58 calories, respectively. 

Multiply cost per pound by "cup cost-factor" to get cost per cup. 

Multiply cost per pound by "100-calory cost-factor" to get cost of 
100 calories. 

For example, if rice costs 6 cents per pound, 1 cup costs 2.64 cents 
and 100 calories cost 0.384 cents; whereas corn flakes at 15 cents, per 
pound, cost but 1.59 cents per cup though 100 calories cost 0.93 cents, 
or nearly 2.5 the cost of the rice in equal fuel amount. 

1 The figures in this table are arrived at in the following manner: The weight of a 
"cup" of the article being found by actual weighing, the calorific value can be calculated 
from the analysis (consult data in Government Reports or in "Food Products," by 
Henry C. Sherman, The Macmillan Co.) The cost-factor per "cup" is obtained by 
dividing the number of grams in a "cup" by 453 (the number of grams in a pound) ; the 
100-calory cost-factor by dividing the number of grams in a 100-calory portion by 453. 



DESCRIPTION OF FIG. 43. 

1, flour, 28 gm. (1 oz.) ; 2, raisins (seeded), 29 gm. (1.02 oz.) ; 3, head rice, 29 gm. (1.02 
oz.) ; 4, puffed rice, 29 gm. (1 oz.) ; 5, hominy, 28 gm. (1 oz.) ; 6, sugar, 25 gm. (0.88 oz.) ; 
7, corn flakes, 28 gm. (1 oz.); 8, prunes (four), 39 gm. (1.37 oz.) ; 9, rolled oats, 25 gm. 
(0.88 oz.); 10, figs (two), 32 'gm. (1.12 oz.) ; 11, pearl barley, 28 gm. (1 oz.); 12, beans, 
29 gm. (1.02 oz.); 13, lentils, 29 gm. (1.02 oz.); 14, almonds, 28 gm. (1 oz.) ; 15, almonds, 
shelled, 15 gm. (0.54 oz.) ; 16, filberts (three), 30 gm. (1.05 oz.) ; 17, macaroni, 28 gm. 
(1 oz.); 18, banana, 156 gm. (5.52 oz.) ; 19, cauliflower, 328 gm. (11.57 oz.) ; 20, onion, 
228 gm. (8.03 oz.) ; 21, potato, 150 gm. (5.27 oz.) ; 22, apple, 212 gm. (7.49 oz.) ; 23, 
spinach, 418 gm. (14.76 oz.) ; 24, orange, 268 gm. (9.45 oz.) ; 25, celery, 671 gm.(23.67 oz.) ; 
26, carrot, 286 gm. (10.08 oz.) ; 27, cabbage, 376 gm. (13.26 oz.). 



316 



FOOD 












(up, 


Cup, 


Cup 


100 calorics 


fiiams. 


calories. 


Cost-factor. 


Cost-factor 


Rolled oats 70 


290 


0.154 


0.055 


Scotch oats . 






161 


653 


0.352 


0.055 


Corn meal 






180 


640 


0.396 


0.062 


Corn flakes . 






48 


178 


0.106 


0.062 


Hominy . 






162 


588 


0.353 


0.062 


( 'racked wheat . 






175 


657 


0.385 


0.062 


Cream of wheat 






175 


657 


0.385 


0.062 


Farina 






180 


669 


0.395 


0.062 


Petti john 






77 


280 


0.170 


0.062 


Grape nuts ■ . 






160 


575 


0.351 


0.059 


Barley (pearl) . 






200 


732 


0.440 


0.062 


Rice (head) . 






200 


723 


0.440 


0.064 


Tapioca . 






180 


653 


0.395 


0.062 


Macaroni 






100 


364 


0.221 


0.062 


Flour 






114 


408 


0.254 


0.062 


Bread crumbs . 






80 


247 


0.176 


0.056 


Sugar, granulated 






200 


820 


0.440 


0.055 


powdered 






160 


656 


0.350 


0.055 


brown 






150 


585 


0.330 


0.057 


Molasses 






. 320 


943 


0.705 


0.077 


Milk .... 






. 244 


175 


0.540 


0.320 


condensed 






. 270 


870 


0.600 


0.068 


Cheese, grated . 






. 100 


456 


0.221 


0.044 


20 1 


91 1 


0.044 


0.044 


Butter 180 


1116 


0.400 


0.028 


Butter 12 1 


93 1 


0.026 


0.028 


Salad oil 180 


1740 


0.400 


0.024 


12 1 


116 1 


0.026 


0.024 


Peanuts, shelled . . . 140 


790 


0.310 


0.040 


Beans, dried .... 200 


706 


0.440 


0.064 


Peas, dried 200 


728 


0.440 


0.062 


Lima beans, dry . . . 200 


712 


0.440 


0.064 


Lentils 200 


715 


0.440 


0.064 


Prunes 180 


475 


0.395 


0.086 


Dates 180 


576 


0.395 


0.064 


Raisins, seeded . 






. 160 . 


563 


0.350 


0.064 



As an example of calculation to ascertain the calorific value of a 
recipe and the cost, together with the economy effected by substituting 
cheaper ingredients, the following recipe for gingerbread ma}' be 
chosen : 



\ cup butter 372 calories at 40 cents per pound 

1 cup molasses 943 calories at 4 cents per pound 

1 egg 74 calories at 48 cents per dozen 

2 f cups flour 1122 calories at 4 cents per pound 

1 1 teaspoonfuls soda 
\ teaspoonful salt 
1 teaspoonful cinnamon 
1 teaspoonful ginger 
\ teaspoonful clove 
f cup boiling water 



5.33 
2.82 
4.00 
2.80 



0.50 



2511 calories at a cost of 



15.45 cents 



Tablespoon. 



FOOD SELECTION AND PREPARATION 317 

COST OF 100 CALORIES, 0.615 CENT. 

Same recipe, using substitutes: 

£ cup peanut oil (salad) . . 580 calories at 22 ceDts per pound 2 . 93 

1 cup molasses 943 calories at 4 cents per pound 2.82 

f cup milk 132 calories at 5 certs per pint 2.10 

2f cups flour 1122 calories at 4 cents per pound 2.80 

Spices and soda as above 0. 50 

No water required (milk) 

2777 11. 15 cents 
Cost per 100 calories, 0.402 cents. 

Saving of ^ cost in fuel value (35 per cent.). 

Saving of \ cost of loaf (27 per cent.). 

Food Selection and Preparation. — In the preceding paragraphs, the 
fuel value of foods has been the chief consideration. It is quite evident 
that this is merely one of the fundamental considerations. The 
quality of the individual articles making a part of the dietary and the 
way in which the articles are prepared for consumption are also of 
paramount importance. Food to be utilized must be digestible and 
assimilable and, to obtain full benefit, the dishes forming a meal 
should be appetizing. In this country there are two very common 
delinquencies in this respect. One of these is the failure to sufficiently 
cook cereals or bake bread, cake or pastry. These latter should not 
be doughly when chewed, but break up and readily mix with the saliva 
during mastication. The other common error is in seasoning. Cereals, 
to take these as an example, are frequently rendered palatable only 
when overloaded with sugar, through a failure to appreciate that a 
proper amount of salt will develop the natural and delicate flavor 
peculiar to each variety of grain. Masking this flavor with sugar 
reduces all cereals to a very nearly common level and limits the 
pleasures of change. In preparing meat for the table, particularly 
stews which are relatively economical, the advantages of slow, pro- 
longed cooking is frequently overlooked. The changes which make 
the meat digestible are not readily brought about in a brief time. 
Simmering for a considerable period is better than rapid boiling of 
brief duration. The meat is rendered more tender and the flavor is 
conserved. When coal is used for cooking, this can be accomplished 
on the back of the stove. If gas is employed, a properly constructed 
fireless cooker can be used to maintain an adequate temperature to 
complete cooking after the initial heat has been attained (real boiling 
until all is heated through) on the range. This applies not only to 
stews, but to cereals, which can be started in the evening and should 
be warm enough without reheating for breakfast. 

When substitutions are made in an acceptable recipe, neither the 
flavor nor the essential quality of the constituents should be appre- 
ciably altered. If the original recipe calls for protein constituents 
of a certain class, proteins of the same class should be contained in 
the substituted recipe, or should be supplied by some further addition. 
Milk, for example, may be used for eggs insofar as the proteins are 



318 FOOD 

concerned, but if the texture of the product in the original is dependent 
upon beaten eggs for its lightness, this texture must be attained in 
other ways, e. g., by the use of baking powder, to avoid disappointment 
in the result. It is in these directions that the skill and ingenuity of 
the experienced cook have ample opportunity for display. In the 
selection of protein constituents of a recipe, regard must also be paid 
to the differences in quality, the presence of vitamines, etc., that 
characterize proteins from various sources. It should also be recalled 
that fats are not all equivalent, butter, for example, containing con- 
stituents in small amount not present in highly refined vegetable 
oils. But many of these deficiencies can be made good in ways not 
precluding the economies attainable by relatively cheap substitutes. 

The important role played by fruit and vegetables in a dietary 
should not be overlooked. Either fruit or vegetables should form a 
part of every meal but the simplest. One reason is that most vegetables 
and some fruits contribute indigestible cellulose (vegetable fiber) which 
gives bulk to the meal, thereby promoting the penetration of digestive 
secretions and the propulsion of the mass along the digestive tract. 
By attention to this matter, habitual constipation can often be avoided. 
This value of vegetables and fruit is a mechanical one. 

But fruit and vegetables also have a somewhat more subtle chemical 
value which deserves attention. They contain salts of the fixed alkalies 
which on combustion in the body yield carbonates rendering the ash 
basic. They constitute the chief source of these alkalies. The proteins, 
except milk, and carbohydrates, with the exception of the potato, 
which may also be classed as a vegetable, and sugar leave an acid ash 
when burned. The natural fluids of the body are neutral or faintly 
alkaline according to the criterion employed and this reaction is 
jealously guarded by physiological means during health and appears 
to be of importance for the normal processes of life. 

While the pathology of chronic rheumatic disorders is intricate, 
there is probably a connection between these troubles and an inappro- 
priate diet. Within this domain the suitable balancing of acids and 
bases probably plays some part, and an intelligent dietary will include 
such considerations. To maintain health, it appears desirable that 
the residues of combustion, the ash of the food, should not be too 
preponderatingly acid. 

It is interesting in this connection to note that many of the com- 
binations that are generally acceptable in daily life offer illustrations 
of a tendency to balance acid and basic constituents. Thus pork 
(acid) and beans (basic) or apple sauce (basic), corned beef and cabbage, 
rice and raisins, cheese with salads (basic because the vegetable acids 
are consumed and carbonates formed), mutton or game and jellies, 
bread and cheese (both acid) with lettuce, fruit or onion, steak smoth- 
ered in onions. Examples occur on every hand, as though the experi- 
ience of the race was emphatic in recognizing the importance of avoid- 
ing an excess of acid residue following the consumption of any meal. 

In further illustration, the following analysis of light breakfasts 
is given: 



FOOD SELECTION AND PREPARATION 



319 



BREAKFASTS. 



Coffee: 
Milk . 
Sugar 

Roll 

Butter . 



Weight, 
grams. 

145.0 
12.5 
36.0 
13.0 



Oatmeal . . . 25.0 
Cream, 18 per cent. 51.0 



Egg . . 
Toast, 1 piece 
Bacon . 



Orange . 



Apple, fresh 
Peach, fresh 
Prunes (dry) 
Figs (dry) . 
Dates (dry) 



56.0 
17^0 

. 268.0 



212.0 

297.0 

39.0 

32.0 

32.0 



Protein. 
19.0 

13^0 

0.5 

32.5 

16.1 

5.1 

53.7 

26.0 

6.5 

6.7 



Calories. , 

Fat. Carbohydrates. 
51.62 29.38 







159.12 
15.0 

81.7 

255.82 

48.0 

4.0 

93.3 



92.9 401.12 
2.6 2.7 



95.5 

2.6 
6.8 
2.8 
5.4 

2.4 



403.82 

5.66 
2.64 

8.54 
7.12 



50.0 
79.0 



158.38 



13.2 



240.48 



39.5 



279.98 
91.1 

371.08 

91.74 

90.56 

97.2 

86.06 

90.48 



Total. 
100.0 
50.0 
100.0 
100.0 

350.0 
100.0 
100.0 

550.0 
74.0 
50.0 

100.0 

774.0 
100.0 

874.0 

100.0 
100.0 
100.0 
100.0 
100.0 



Ash.i— -, 

Acid. Basic. 

2.6 



0.0 
3.0 



3.0 
7.0 



0.8 



10.8 



10. 



2.6 



2.6 



2.6 
11.0 



6.0 
12.2 

8.0 
32.3 

3.2 



The very simple breakfast of 350 calories yields a basic ash due to 
the milk in the coffee. The addition of oatmeal and cream makes a 
nearly neutral combined ash. But when the diet becomes more dis- 
tinctly protein by including egg and bacon, the residue becomes 
decidedly acid. This may be corrected with an orange or some other 
fruit. All this is quite in harmony with the varying customs. If fish 
or meat are taken at breakfast, potato usually accompanies the more 
hearty protein meal, and the neutrality of the ash is thus secured. 

In the preceding pages normal conditions have been the subject of 
consideration. The results of departures from such normal conditions 
also claim attention. 

Beyond the question of calories, food may affect health in a variety 
of ways. 

Excessive Amounts. — As already indicated, the quantity of food 
required to maintain the body in health varies with the climate and 
season, clothing, occupation, work, etc., of the individual. The ten- 
dency in this and other civilized countries is to eat excessive amounts 
of food. The art of cooking has produced so many appetizing dishes 
that more food is consumed than is necessary for the maintenance of 
the best bodily health. Overeating results in overloading the digestive 
organs; the stomach and intestines become enlarged; the liver 
engorged; and conditions ensue leading to degenerative changes. 

1 The unit in which the acid or basic value of the ash is expressed is 1 c.c. of a normal 
solution of an acid or alkali. If sodium hydrate be the base chosen, this amounts to 
40 mg., the equivalent of 84 mg. of sodium bicarbonate. The basic value of 100 calories 
of milk is therefore equal to 0.2184 gm. of sodium bicarbonate, or 3.37 gr. One hundred 
calories of figs is equivalent to over 2.7 gm. of sodium bicarbonate, or 41.5 gr. For 
further information on this subject, see "Food Products," by H. C. Sherman, from which 
the above data are taken. 



320 FOOD 

These, when chronic, tend to produce such diseases or so-called " dia- 
theses" as obesity, gout, rheumatic affections, fatty heart, lithemia, 
oxyuria or the formation of calculi (renal, vesical or hepatic). Con- 
gestion of the liver and the condition known as " biliousness/ ' with 
coated tongue, concentrated urine, constipation, headache, etc., are 
almost certain to be the result. 

Insufficient Diet. — Lack of sufficient food for the maintenance of 
the body is starvation, while a failure to assimilate food is inanition. 
In the majority of cases, six to ten days is the limit of life with complete 
starvation, though professional fasters claim to have lived forty days 
without anything but water. Appetite or hunger is not always the 
best guide to the need of the body for food. 

Famine and pestilence are often mentioned together in describing 
great epidemics occurring on a large scale, such as those of plague, 
small-pox, typhus fever, and other pestilential diseases, which are 
called famine fevers. But there is no definite relationship so far as 
we know, between famine and epidemics. 

Unbalanced Diets. — The lack of variety or monotony in the food, 
or the insufficiency or excess of certain elementary food substances in 
the diet, known as unbalanced diets, may seriously affect health. Thus 
anemia may be produced from lack of meat or other food; scurvy from 
lack of fresh fruits and vegetables, with excess of salt food; rickets 
and marasmus from an excess of starchy food and lack of animal food, 
mineral salts, etc., a form of acidosis in babies from too much fat; 
acne or eczema from too much carbohydrate; constipation from too 
concentrated diet and too little water between meals; and gout, and 
possibly rheumatism, from faults of various kinds in the diet. Many 
other disorders are attributed to unbalanced diets, as beri-beri, for 
instance, a disease occurring chiefly in those countries where polished 
rice is the main or monotonous article of diet; and pellagra, an affection 
formerly thought to be due to the eating of spoiled corn, but now 
believed to be caused by a faulty diet, consisting largely of maize or 
Indian corn and a deficiency of proteins. 

The need of a mixed diet is emphasized in certain "dietary diseases" 
resulting from a one-sided diet. Failure of growth and causation of 
certain diseases have occurred with diets which chemical analysis 
showed contained the requisite foodstuffs — protein, sugars, starches, 
fats, etc., and it became evident that there are other indispensable 
elements of our food which as yet cannot be definitely ascertained 
by the usual methods of chemical analysis. These constituents are 
termed "vitamins." Valuable experimental researches have been 
made by F. E. Hopkins (1906), Shepp (1909), Fraser and Stanton 
(1907), and Casimir and Funk (1911), which strongly suggest the 
presence of an essential unidentified principal in diets as necessary for 
growth and the maintenance of physiologic well-being as the known 
food constituents. Although direct evidence is available only in the 
case of beri-beri, Funk assumed the existence of a specific vitamiue 
in the case of scurvy, pellagra and rickets. This assumption, however, 
is denied by McCullom and others who claim that scurvy, pellagra and 



MEAT INSPECTION 321 

rickets are due, not to lack of a specific vitamine, but to lack of other 
dietary essentials or to bacterial or other causes. (See chapter on 
Vitamins.) 

Salts in the Diet. — Certain salts, when derived from fresh vegetables 
and fruits, are also indispensable articles of food. These salts are 
formed by the common organic acids, such as citric, tartaric, malic, etc., 
in combination with the bases, calcium, sodium, potassium, etc. When 
absorbed they form carbonates in the body and aid in maintaining the 
alkalinity of the blood. It is to the lack of sufficient potash salts, 
especially potassium carbonate, that scurvy is thought to be partly 
due, and this condition is intensified by an excess of salt in the diet. 
Deficiency of calcium phosphate in the food of infants and growing 
children leads largely to rickets. As the result of poor development, 
due to lack of this salt, the bones become soft and bend under the strain 
of the body weight. Again, an insufficiency of inorganic* salts in the 
food impoverishes the hemoglobin of the red blood corpuscles, upon 
which depends their oxygen carrying power, and thus tends to the 
production of anemia and other disorders. 

Meat Inspection. — The sanitary control of food is necessary for the 
protection of the consumer. This is especially true of the animal foods 
such as meat and milk which are the most likely to become infected or 
decomposed. Meat inspection is important not only on account of 
the long distances over which it has often to be transported to market, 
when there may be danger of eating it in an infected or diseased con- 
dition, but the mere handling of flesh of some animals may suffice to 
convey infection to those who touch it, with anthrax or glanders. 
Diseases among cattle, sheep and swine, such as rinderpest, foot-and- 
mouth disease, Texas fever, etc., may also be detected and prevented 
by systematic meat inspection. 

The Federal Meat Inspection Law, which is administered by the 
Bureau of Animal Industry under the direction of the Secretary of 
Agriculture, provides for the inspection of cattle, sheep, goats and 
swine, the meats or meat-food-products, which are to enter into inter- 
state or export trade. This law does not apply to meats butchered, 
dressed and sold within the State, though much of the meat slaughtered, 
shipped, sold and consumed wholly within a single State comes under 
Federal inspection. Many States, moreover, have passed laws similar 
to the Federal law to protect their own citizens, so that there is a more 
or less uniform method of meat inspection throughout the country. 
The Federal law provides for the inspection of the slaughter houses, 
the packing houses, the meat canning, salting, rendering or similar 
establishments; for the inspection of animals before and after they are 
slaughtered and for the condemnation and distinction of diseased 
carcasses or parts of carcasses. The sanitary conditions of the establish- 
ments and the health of the employes are also under the control of this 
law. Carcasses or parts of carcasses with the following diseases or 
conditions are condemned, depending on circumstances: Anthrax, 
pyemia and septicemia, vaccinia, rabies, tetanus, malignant epizootic 
catarrh, hay cholera and swine plague, actinomycosis, caseous lymph- 
21 



322 FOOD 

adenitis, tuberculosis, Texas fever, parasitic icterus, hematuria, mange 
or scab, trichinosis, tapeworm, infections that may arise from meat 
poisoning, etc. 

The Changes in Food Wrought by Cooking. — Within a household the 
hygiene of the table centers on the range. 

"Cooking," says Rosenau, "may be regarded as the greatest sani- 
tary innovation ever introduced by man to protect himself against 
infection." Metchnikoff dwells upon the great sanitary value of cook- 
ing. In the animal as well as in the vegetable world some natural 
foods are ready for digestion, as milk, raw eggs too, are perfectly diges- 
tible and are often given to invalids. "Raw meat cures" have also 
been proclaimed, and it has been found that tender and juicy raw meat, 
if chopped very fine to break the connective tissue, is well digested. 
But raw meat does not seem palatable to most of us, while cooking, 
especially broiling, brings out its flavor and makes it more acceptable 
to the taste, a by no means unimportant factor in good digestion. 
Moreover, the heat required for cooking kills all forms of infection and 
thus renders food safe, so far as these dangers are concerned. The 
heat also destroys most of the toxic products of decay; though some 
foods may contain heat-resisting poisons such as muscarin, the poison- 
ous principle in certain toadstools, and a poison sometimes found in 
mussels. But foods do not ordinarily contain heat-resisting poisons 
resulting from bacterial decomposition. 

Food thoroughly cooked throughout reaches a temperature of 
140° F. (60° C), at which degree of heat non-sporebearing bacteria 
are for the most part destroyed. But much meat and many vegetable 
foods are preferred rare or underdone, and in such cases the outside of 
a large joint of meat, for instance, may be thoroughly cooked or even 
dressed, while the inside may be practically raw or not sufficiently 
cooked to destroy any parasites present. 

One of the objects of cooking is to soften the connective tissue, 
thereby turning it into a sort of gelatin, and by loosening the muscle 
fibers of meat and coagulating the albumen, to render it more savory 
and tender, and thus to make it more digestible. But unfortunately, 
unless the meat is very tender from the start, this requires a longer 
application of heat than is needed to cook the delicate albumen all full 
of flavors too easily lost. To soften the connective tissue without over- 
cooking the albumen, and yet to cook it sufficiently to bring out these 
flavors, constitutes one of the problems of meat cooking. Tough meats 
may be pounded to separate the connective tissue bundles, or may be 
chopped or minced, or they may be steeped for several hours in fresh 
or sour milk or in vinegar. Cooking breaks open and softens the 
cellulose and fibers of vegetables, causes the starch grains to swell 
and burst, and converts the insoluble starch into dextrine or soluble 
starch. 

Exposure to steam at 158° F., for a long time has the same effect 
as cooking foods thoroughly, and this possesses the advantage of 
retaining the juices, and preventing burning or the results of over- 
heating. Moreover, the process requires little or no attention. The 



MEAT INSPECTION 323 

so-called "tireless cookers" now on the market in various forms are a 
modification of this method. These consist simply of an insulated box, 
in which the food after heating is placed in suitable vessels, and kept 
at a temperature of over 158° F. (70° C.) for several hours. 

As to the choice of cooking utensils, it may be said that the use of 
brass and copper are not advisable, because of the verdigris or green 
rust, the poisonous acetate of copper, which is apt to form on them, 
unless kept scrupulously clean. Acid foods should not be cooked in 
copper pots, nor should milk or substances containing sugar be kept in 
such vessels, because of the possible extraction of copper by these acids. 
Of metal ware, tin, nickel, and aluminium are the best. Enameled iron 
is satisfactory, provided it does not contain lead or become chipped. 

Methods of Cooking. — Herein lies the fine art of cooking. Simply 
stated, the methods in general use are: (1) roasting; (2) broiling; (3) 
boiling; (4) frying; (5) stewing. 

Roasting and broiling involve practically the same principle, as 
also does baking, the cooking being done by the medium of heated air. 
The dry heat of the coals affects the outer layer of the meat, as does 
the hot air of the oven. There is a considerable shrinkage, due mainly 
to the loss of water. The heat coagulates the exterior of the meat and 
then prevents the further loss of juices and drying up. It is necessary 
to baste the meat by pouring water or melted hot fat over it from time 
to time, in order to obtain sufficient heating of the meat throughout 
a large joint without the danger of burning it. 

In boiling the meat is placed in boiling hot water, if it is desired to 
maintain the flavors within the mass, the albumen being thus coagu- 
lated at once at the surface. If a rich broth or soup, on the contrary, 
is desired the meat must be placed in cold water and gradually heated, 
the soluble albumens in this way being allowed to pass out into the 
water. 

Frying or so-called "dry frying," consists in placing the meat or 
other food into boiling hot fat, lard, or vegetable oil, which causes a 
rapid coagulation of the albumen on the surface and a retention of the 
flavors and juices, as in the first mentioned process of boiling. If the 
fat is not boiling hot it will penetrate the tissues and cause the meat 
or other food to become greasy. For this reason fried substances are 
apt to be indigestible. 

In stewing the meat is cut into pieces and placed in cold water, which 
is gradually heated to about 180° F. (84° C), at which temperature it 
is kept for several hours. If heated too much, the meat becomes 
tough and stringy. 

The choice of methods of cooking depends largely on the quality of 
the meat to be cooked. Trimmings and tough portions may be made 
into soup. Rather better pieces, but still requiring long cooking to 
soften the connective tissue, may be made into a stew or ragout, or 
if the piece is large and compact, boiled in water; but meat that is 
tender and juicy should be boiled, roasted or broiled, choosing oftenest 
the last two methods, because of the more perfect retention of the 
juices and flavors, 



CHAPTER X. 

VITAMINES. 

By ALFRED F. HESS, M.D. 

Until recently foods were valued largely in proportion to their 
caloric content; thus the potato was regarded as a highly nutritious 
food, whereas the tomato was looked upon as possessing almost no food 
value whatsoever. Recent investigations, however, have caused us to 
modify and enlarge our views in this regard. It has come to be realized 
that in addition to the proteids, carbohydrates and fats, with an 
appropriate amount of salts and water, there are other less clearly 
defined substances which are of essential importance for nutrition and 
especially for growth. These newly discovered substances have been 
termed " vitamines" (Funk), " accessory food factors," "food hormones/' 
by various physiologists, or have been designated according to their 
solubility as "fat soluble" or "water soluble." Their designation is of 
minor importance, more particularly as none has been isolated in a 
pure state, and therefore correct chemical terminology is at the present 
time impossible; nor is their mode of action understood. It has been 
suggested frequently that they are not utilized directly by the body, 
but that they function as catalyzers. This conception emanates 
from the fact that they are required in minimal amounts in order 
to supply the body needs, and because this action is so striking in its 
rapidity. Another view which is attractive, but which also has no 
experimental basis, is that they act as hormones in connection with the 
functions of the glands of internal secretion. 

At present it may be stated that there are three distinguishable 
vitamins. The first discovered was the vitamine reported by Hopkins 
as essential to the growth of rats, and later associated with beri- 
beri in man and polyneuritis in fowl. A second is the fat-soluble 
vitamine described by McCollum and by Osborne and Mendel, and a 
third is the vitamine studied by Theobald Smith, by Hoist and others, 
and which is essential to the prevention of scurvy. It is probable that 
there are still more of these interesting substances which are essential 
to our welfare, and that their discovery will lead to the recognition of 
further nutritional disorders. The lack of any of these three dietary 
factors leads to a definite disturbance which has been termed " a 
deficiency disease." This term is open to the criticism that it is by no 
means certain that a deficiency is the sole cause of the disorder, for a 
secondary toxic factor may well play a role. In addition to the dis- 
orders definitely occasioned by the lack of these vitamines, there are 
others w hich have been included in this group with more or less validity, 



VITAMINES 325 

such as rickets, pellagra, osteomalacia, war edema, the "mehlnaerscha- 
dung of Czerny," and various indefinite diseases involving the nervous 
system. It will be well to consider merely the three " vitamines" which 
have been identified biologically, and to review briefly the symptoms 
which develop when they are supplied in insufficient quantity to 
animals and to man. 

The experimental basis of our knowledge of the w r ater-soluble vitamine 
was, as mentioned above, largely the result of the work of Hopkins, 
who found that animals could not live and grow on a diet of purified 
food substances, but that the addition of a very small quantity of a 
natural food, such as milk, was sufficient to render the dietary complete. 
Later it was shown that absence of this vitamine is the essential factor 
in beri-beri, a disease of the nervous system prevalent in the Far East. 
This disease is brought about when the diet consists largely of polished 
rice, and is promptly cured by substituting the unpolished rice for the 
white variety. As shown by Eijkman, a similar disease can be repro- 
duced in fowl by means of a diet of polished rice and cured by the 
addition of the pericarp or an alcoholic extract of this substance. This 
vitamine is widely distributed among the foodstuffs; it is present in 
most concentrated form in yeast, and is to be found in all seeds and 
eggs. In the seeds it resides in the aleurone layer and particularly in 
the germ or embryo, but is completely absent in the endosperm. It is 
also present in other seeds, such as peas and beans, and in the various 
leafy vegetables, such as cabbage and spinach, which are used exten- 
sively for human food. Milk and eggs contain it in less degree, and 
starch, sugars, refined flours, fats and oils are practically devoid of 
the " antineuritic vitamin." It is evident that a people living on a 
varied diet will obtain a sufficient amount of this essential substance. 
If the dietary is greatly restricted, however, if it consist mainly of 
polished rice or finely bolted flour, beri-beri will gradually develop. 
This disease has been prevalent for many years in the Philippines, in 
certain parts of China and India, in the Dutch Indies and the Malay 
States, owing to the prejudice of the natives against brown rice. 
However, since the mode of prevention has become recognized it has 
become much less frequent. In the Japanese navy, where previously 
it attacked thousands every year, it has been almost eliminated by 
simple dietary measures. Sporadic outbreaks have occurred in the 
United States and in England, and it is probable that occasional cases 
develop from time to time which pass unrecognized. 

In addition to the water-soluble vitamine the body requires a supply 
of fat-soluble vitamine. This substance is by no means so widely 
distributed in nature as the water-soluble vitamine. It is present in 
largest amount in milk and in eggs, and in considerable concentration 
in the glandular organs such as the liver and the kidney, and further- 
more in the cells of the leafy vegetables, for example in spinach and 
cabbage. The seeds of wheat, rye, barley, oats, etc., contain also small 
amounts of this vitamine, but the finely bolted flours prepared from 
these seeds are devoid of fat-soluble vitamin, as are the vegetable fats 



320 VITAMINES 

and oils. It is therefore quite possible that even a liberal diet may 

contain an insufficient quantity of this dietary essential. The symp- 
toms and the pathological processes resulting from an inadequate 
supply of this vitamine have not yet been thoroughly investigated. 
It has been shown, however, that infants who have been fed for long 
periods on skimmed milk develop a form of eye disease (xerophthalmia) 
which yields promptly to the addition of cream or butter to the dietary. 
There are probably other nutritional changes, especially in infants, 
which are occasioned by a deficiency of this substance. 

The third so-called "deficiency disease" is scurvy, which is generally 
referred to as adult scurvy or infantile scurvy (Barlow's Disease). 
Experimental studies of this disorder have been carried out on the 
guinea-pig, whereas investigations of the other vitamines have been 
made on the rat. This disorder results from deprivation of fresh food 
for several months, especially of fruits and of vegetables. It takes 
many months to bring about this "avitamine" disorder, so that there 
are necessarily many rudimentary or latent cases. In the days of the 
sailing vessel scurvy was associated with long ocean voyages, and 
occurred frequently among sailors who had to subsist mainly on a diet 
of hard-tack and salted meats. Today it is endemic in Russia, and 
occurs only sporadically throughout Europe and the United States 
and probably most parts of the world. During the late war a decided 
increase in its incidence was reported both among the military forces 
of the eastern front and the civilian population of England and Europe. 

Barlow's Disease is almost never encountered among breast-fed 
infants but develops in those who are fed cow's milk which has been 
heated and subsequently kept. It is met with particularly in babies 
who, for a period of months, have been given a formula of boiled or 
pasteurized milk, to which a proprietary food has been added. Scurvy 
develops more rapidly if the amount of heated milk is insufficient. 
This vitamine is far more sensitive to heat than are the other two, 
especially when an alkali has been added to the food. All babies who 
are receiving heated milk should also be given an antiscorbutic. Unless 
this is provided, scurvy is apt to develop with symptoms of pallor, 
hemorrhage of the gums, painful swelling of the bones, and marked sus- 
ceptibility to infection. One of the most popular antiscorbutics for 
this purpose is orange -juice. Recently Hess and Unger have suggested 
the use of a more economical antiscorbutic, namely, canned tomato, 
strained and given to the amount of one ounce daily. Prunes possess 
practically no value in this regard. 

All fruits contain this vitamine to some degree, oranges and lemons 
possessing it to the largest extent. . Of the vegetables, the cabbage, 
onion, tomato, swede, and potato are particularly rich in this essen- 
tial food factor. Meat when raw contains it in sufficient amount 
to afford protection if large quantities are consumed. Owing to 
this fact the inhabitants in the polar regions rarely develop scurvy, 
and recent Arctic expeditions have remained free from this scourge. 
Grains and seeds are devoid of this vitamine ; when they are sprouted, 



VITAM1NES 327 

however, they develop marked antiscorbutic potency. Advantage of 
this fact was taken in the World War by the English, who made use of 
germinated pulses to supply antiscorbutic food for the army where 
fresh vegetables could not be included in the ration. When vegetables 
are dehydrated they lose most of their antiscorbutic potency, that is to 
say, when the method is carried out according to the dehydrating 
processes now in vogue. It is quite possible, however, that these 
methods will be improved so that they will retain a large part of their 
vitamine content. Until this comes to pass, however, we must see to 
it that the dietary contains fresh vegetables or fresh fruit. 



CHAPTER XL 

THE PRESERVATION AND ADULTERATION OF FOOD. 

By J. P. ATKINSON, B.S. 

PRESERVATION OF FOODS. 

There has been no time in the history of man, as we know it, when it 
has not been found desirable and necessary to save food for various 
periods of time. The Arabs of the desert, the Indians on the great 
plains and the Esquimaux in the frozen north, as well as people in the 
great cities of the past, have been accustomed to use means of preserv- 
ing their food. These methods consisted of the simple physical methods 
that are still in use by drying in the air and sun and freezing and the 
use of chemical substances not only natural and inherent in foods, 
such as the essential oils in spices and lactic acid found in milk by 
natural means, but those selected for the purpose such as salt and 
vinegar. At present we have improved these methods in some respects 
and have added to them some that are not as harmless to the consumer. 
Some of the latter, namely, salicylic acid and benzoic acid, are found in 
small quantities naturally, either alone or together, in a number of 
edible vegetable foods. 

Traphagen and Burke determined salicylic acid in the following: 

CurraDts 0.57 milligrams per kilo fruit.' 

Cherries . . . . ' 0.40 

Plums .0.28 

Crabapples 0.24 " " " 

Grapes 0.32 

Benzoic acid was determined in whortleberries to be 0.6 to 0.8 gm. 
per liter. Raspberries and horseradish contained either salicylic acid 
or phenol, and apricots and peaches and strawberries contain salicylic 
acid in appreciable quantities, while currants contain both benzoic 
and salicylic acid, and cranberries are well known to contain a con- 
siderable amount of benzoic acid. It has also been noted by other 
chemists that boric acid is a natural constituent, in small quantities, 
in grape and other plants used as foods. 

F. C. Cook and J. B. Wilson have shown experimentally that plants 
growing in a soil containing boron will absorb it in varying proportions, 
depending upon the plant, soil, moisture, quantity of and solubility 
of the boron compound. 

Fluorine must likewise be a constituent of some of our foods, since 
it is an important constituent of the teeth. According to Dr. Long, 
\ ounce of salt is about as much as one can consume per day. Some 



PRESERVATION OF FOODS 329 

might stand 1 ounce per day for a while, but 2 ounces per day would 
sicken and kill, possibly, § ounce is sufficient per day for body needs. 
Dr. Long also remarks that "the pure oils extracted from spices are 
active poisons in the real sense of the word." 

Sulphurous acid is probably an intermediate product in the metab- 
olism of cystin, the sulphur containing ammo-acid, found in egg white, 
casein and serum globulin. There is reason to believe that formalde- 
hyde is a natural product, found during alcoholic fermentation under 
certain conditions. Likewise many of our most prized vegetable foods 
contain compounds that, considered alone, would be immediately 
condemned as violent poisons. Oxalic acid in rhubarb and hydro- 
cyanic acid in certain varieties of beans, cassava, and peach and 
plum kernels illustrate this fact. 

Foods naturally containing these preservatives and poisons cannot 
be condemned, yet, to quote Folin, "Formaldehyde, salicylic acid, 
boric acid, borax, sulphurous acid and sulphites cannot be defended as 
ingredients of food. The human body does not produce them and has 
not developed any special mechanism for excreting them. There is 
no sound reason for their use. Negative harmful results do not mean 
that the human is not injured." 

This statement refers to these preservatives when added to food by 
manufacturers or others interested in prolonging their usefulness for 
commercial purposes. If used for this purpose, preservatives may 
also be useful in hiding inferiority or in actually enabling the food 
dealer to sell food unfit for human consumption. The use of formalde- 
hyde in destroying the odor of rotten eggs is a striking example of this 
practice. Merely because fruits and vegetables contain such com- 
pounds as salicylic acid, boric acid and fluorine and other substances 
known to be injurious, it cannot be reasoned that it is proper, from any 
point of view, to deliberately add these substances as preservatives to 
foods. 

Rideal states that "a disinfectant kills organisms, including spores. 
An antiseptic prevents animal and vegetable substances from under- 
going decomposition." Food preservatives that have been used include 
both disinfectants and antiseptics. Xo preservative is added to food 
in such proportions that it can be termed a disinfectant, and in most 
cases added chemical preservatives must be helped in their work by 
processing with heat if the food is to be kept more or less indefinitely. 
The relative value of a number of compounds used as food preserva- 
tives is given in a "table of antiseptic substances" by Miguel. 

The relative values are as follows: 

Hvdrogen peroxide 1 to 20,000 

Salicylic acid 1 to 1,000 

Benzoic acid 1 to 909 

Boric acid 1 to 143 

Sodium salicylate 1 to 100 

Sodium borate 1 to 14 

Alcohol Ito 10 

Sodium chloride (salt) 1 to 6 



330 PRESERVATION AND ADULTERATION OF FOOD 

In the same table appears the following: 

Mercury iodide 1 to 40,000 

Sih-r-r iodide I to 30,000 

Mercury bichloride 1 to 14,000 

Phenol (carbolic acid) 1 to 333 

It will be noted that hydrogen peroxide is among the most powerful, 
while benzoic acid is nearly three times as efficient as phenol. 

In criticising a food preservative several phases must be considered : 

1. Is it harmless or deleterious to health? 

2. Has it food value? 

3. If it has no food value, can a preservative having food value be 
used just as satisfactorily? 

4. Does the preservative allow improper food material to be used in 
the preparation of the food? 

In applying these criteria to food preservatives many animal experi- 
ments have been made, and feeding experiments on humans, in addition 
to recorded observations that have not been systematically planned, 
through physicians' records. 

Those perhaps causing the greatest interest are the studies of 
Harvey Wiley on his "poison squad" and those subsequently carried 
out by the Referee Board of Scientific Experts. The findings of these 
two bodies of investigators will be mentioned later in discussing the 
individual preservatives available for use. 

Preservation of food depends upon the inhibition or death of fermen- 
tive and putrefactive organisms and the restraint of enzymic action in 
the tissues. For this purpose the following physical methods and 
chemical agents have been used: 

Drying and Removal of Water. — 

(a) In the sun and air. 

(b) In chambers or tunnels by means of dry air. 

(c) By partial or complete vacuum system. 

(d) By heating. 

(e) Salting. 

Freezing and Cold Storage. — 
(a) Heating. 
(6) Pasteurization. 
(c) Sterilization. 
All of these methods, if applied to foods suitable for human con- 
sumption, are legitimate and practicable. 

Chemical A gents. —Chemical agents may be divided into three 
groups: 

(a) Those that are considered t o be harmless to the consumer. 
(6) Those that are known or considered to be injurious to the 
consumer. 

(c) Those whose action on the consumer is still in doubt. 
Under division (a) may be mentioned the following : 

1. Cane sugar. 

2. Salt. 

3. Vinegar, dilute acetic acid. 



PRESERVATION OF FOODS 331 



4. Alcohol. 



.). 



Benzoic acid arid its sodium salt in minimum quantities. 

6. Volatile matter in smoke. 

7. Spices, oils and extracts. 
Under division (b) may be mentioned: 

1. Formaldehyde. 

2. Salicylic acid and its sodium salts. 

3. Boric acid and its salts. 

4. Fluorides. 

5. Pyroligneous acid (liquid smoke). 

6. Formic acid and formates. 

Under division (c) the following may be placed : 

1. Nitrates in pickling fluids. 

2. Peroxides. 

3. Sulphites, sulphur dioxide, sulphurous acid. 

Drying. — The preservation of foods by drying is one of the oldest 
methods as well as one of the most efficient in use. All varieties of 
foods are susceptible of drying. The original method as practised by 
the xAmerican Indian and hunters is still in use. It consists in cutting 
meat into strips and banging them in the sun and wind. The method 
of sun and air drying has also been used largely for fruits. During 
the past few years drying methods on a large commercial scale have 
been developed. In general, it may be said that these depend upon the 
removal of water by regulated heat or by vacuum aided by heat. 
The process in the drying of vegetables and fruits is carried out in 
machines capable of holding large quantities of material and requiring 
from three to twenty-four hours for the process. The various machines 
differ in mechanical construction, but the general principles are the 
same. 

All caloric food value remains unharmed by this process. The 
effect of drying on the vitamin value of foods, however, remains to be 
definitely determined. Preservation by salting and by alcohol owe 
their effectiveness in part to the removal of water, and in this sense 
may be classified under drying methods. If drying of fruits and vege- 
tables is carefully carried out so that only about 8 to 10 per cent, 
water remains, the product will keep indefinitely in sealed containers, and 
when placed in water will again absorb it. Vegetables, such as carrots, 
onions, potatoes, beets, turnips and spinach, regain their original 
forms, and the coloring matter of such vegetables as carrots, spinach 
and parsley, together with their characteristic odors and flavors, will 
remain. Almost perfect desiccation can be produced by fraction ing 
off the water content of a food by successive alcohol extractions. If 
care is used the cell will take up water again and expand, provided the 
desiccation has not been carried too far. Alcohol, however, extracts 
with the w^ater the color, oils and aromatic compounds of the food. 

Cold Storage and Refrigeration. — These terms are sometimes con- 
fused, but their difference is very important. Cold storage is a general 
term and includes refrigeration. The temperature for cold storage 



332 PRESERVATION AND ADULTERATION OF FOOD 

varies, according to the food to be stored, from several degrees below 
freezing to several degrees above freezing. Refrigeration refers to 
freezing temperatures only. 

The temperature employed depends upon the nature of the product 
to be held. Fish and meat may be frozen. Eggs are kept at about 
31° F., since they freeze at 29° F., and would burst if allowed to freeze. 
Such substances as butter may be kept either below freezing or slightly 
above. Fruits are kept a few degrees above freezing. 

Experience has shown that foods are w r ell preserved by cold if kept 
at the lowest temperature that is not physically destructive. Injury 
is caused to cellular foods, such as fish, meat, poultry, eggs, vegetables 
and fruits, through freezing by the bursting of the tissue cells and the 
subsequent loss of juice upon thawing. Thawed meat, fish and 
poultry are also less resistant to the attacks of microorganisms by 
reason of the cell fracture. Even at low temperature, certain micro- 
organisms can develop slowly and may have a deleterious effect. For 
this reason protein foods, that readily undergo putrefaction, must go 
into the freezer only in the best condition. Eggs and poultry are note- 
worthy examples of this need. 

Many States have cold storage laws. These laws control the quality 
of the foods to be held, the length of time in storage, the prevention of 
the restoring of certain kinds of foods when once taken out of cold 
storage and other conditions aimed to protect the consumer. 

Cold storage offers the means of collecting foods at times of abun- 
dance and holding them for distribution during periods of non- 
production. Physiological and chemical investigations have shown 
that cold storage is a safe and reliable method of food preservation. 
A greater variety of foods are made available and food costs are 
stabilized. 

Practically all varieties of foods are preserved in cold storage; for 
example, meats, poultry and game, fish, eggs, vegetables, fruits, nuts, 
butter and oils, and are found to be in excellent condition after many 
months of storage. Refrigerated protein foods should be kept at the 
storage temperature until they reach the consumer. These include 
all varieties of meat, poultry and fish. Since, as already stated, 
freezing damages the tissues and putrefaction begins very quickly 
after thawing it is important that these particular food substances 
should not be put back into the freezer after once having been 
removed. 

Heating. — Preservation by heating is one of the most important 
methods, if not the most important one of keeping foods from spoiling. 

The first method of canning was published by a Frenchman, Appert, 
in 1810. It was taken up in England about the same time and was 
first applied in America in 1839 by Isaac Winslow. Since that time 
the industry has made tremendous advances in all its aspects. Until 
the work of Pasteur, published in 1862, the cause of putrefaction was 
not recognized, and even after the results of Pasteur's work was known 
it required the further work of Tyndall to complete it. Preservation 



PRESERVATION OF FOODS 333 

by means of heating falls into two classes: (1) Sterilization, by which 
all living organisms are killed, including spores, and (2) pasteurization, 
by which only vegetating forms are killed. 

Sterilization or Canning. — This is brought about by placing the food 
material in cans, creating a vacuum, sealing and raising the tempera- 
ture to the thermal deathpoint of the bacteria peculiar to the substance 
being canned. In some cases the material is washed in boiling water 
(blanched) and heated before being placed in the can. This removes 
dirt and kills organisms on the surfaces. It also has the effect of 
swelling the food material, so that the subsequent swelling in the can 
during processing will be reduced. This method is applicable to many 
varieties of foods, such as meats, milk, fish, poultry, vegetables and 
fruits. When glass is used as a container usually some preservative 
must be added. For preserves in glass, sugar must be present in large 
quantities. 

Pasteurization. — Pasteurization is the heating of the food material 
in its container to a degree of heat necessary to kill only the adult 
form of microorganisms. Spores are not killed by this treatment. 
The temperature used varies somewhat with the length of time it is 
applied; 145° F. for thirty minutes is usually used in the pasteurization 
of milk. If a higher degree of heat is used a shorter time of exposure 
is needed, until at 160° F. only thirty seconds is necessary. Pasteuriza- 
tion is of the greatest value in the production of milk free from disease 
organisms, and such milk will keep sweet in the ice-chest for several 
days without appreciable change. 

Cane Sugar. — Cane sugar is used principally in syrups and con- 
densed milk. Besides its deterrent action on the growth of micro- 
organisms it has also the added advantage of having i high food value. 
It is employed for the most part in the preparation of sweetened 
condensed milk, of which it makes about 40 per cent., and in the pres- 
ervation of fruits whole and as jams, jellies and marmalade. 

Salt. In addition to the attraction salt has for water in the tissues 
of meat and fish, salt also has a deterrent action on the growth of micro- 
organisms, and is a necessary food substance as well. It is applied 
directly in the dry state or in the form of a brine. Even in this con- 
centrated condition it does not always kill putrefactive organisms. 
It is used largely for pickling meats and fish. Sometimes saltpeter 
is added to increase its efficiency. Salt impregnates the whole tissue 
in time and therefore must be removed by soaking in water before 
the preserved food is palatable and suitable for consumption. 

Vinegar. — Vinegar resembles sugar in being both a real food and 
preservative for food, and has been in use for centuries for these pur- 
poses. Its active principle is acetic acid. There are several varieties 
of vinegar, each having its own standard of purity, namely, cider, 
vinegar, wine vinegar, sugar vinegar, malt vinegar, distilled, grain or 
spirit vinegar. 

Vinegar usually contains from 4 per cent, to 6 per cent, acetic acid. 
It is a general preservative for meats, fish, shell-fish, fruits, vegetables 



334 PRESERVATION AND ADULTERATION OF FOOD 

and condiments. Pure dilute acetic acid may be substituted for 
vinegar, with satisfactory results, depending upon the type of food to 
be preserved. 

The quantitative determination of acetic acid in vinegar is carried 
out by direct titration with a standard solution of alkali; usually 
tenth normal in strength. This gives the amount of acid present in 
terms of tenth normal acid, and may be readily calculated to per cent. 

To fortify the acidity of vinegar, mineral acids are sometimes added, 
also wood vinegar (impure acetic acid from the destructive distillation 
of wood), substituted entirely or in part. This is a poisonous mixture 
and should have no part in food preparations. Special examinations 
for these forms of adulteration should be made in every vinegar 
examination. 

Alcohol. — Alcohol acts as a preservative not only through its direct 
inhibitory action on organisms, but also as a protoplasmic poison of 
the corrosive type through its dehydrating action when used in strong 
solutions. 

Alcoholic fermentation proceeds until about 15 per cent, of alcohol 
is developed, when fermentation stops. Larger quantities kill organ- 
isms not affected by the percentage which stops its own production. 
Alcohol is also a useful food and stimulant, practically all being oxidized 
by the body. It is used, for the most part, for preservative purposes 
in the home for the preservation of such foods as fruits (brandied 
peaches), mince pies and fruit cake. 

Alcohol is determined quantitatively by distilling, from an alkaline 
solution of known volume (100 c.c.) and weight (specific gravity), an 
equal volume of liquid. This will contain the alcohol. The specific 
gravity of this distillate is determined and the percentage of alcohol 
present read off from the alcohol specific gravity table. From this 
percentage and the specific gravity of the original sample the amount 
of alcohol in the original sample is calculated. 

Methyl, or wood alcohol, is sometimes used as a substitute and as an 
adulterant for ethyl or grain alcohol, and therefore an examination for 
methyl alcohol should always be included in an ethyl alcohol deter- 
mination, since methyl alcohol is poisonous, producing in some instances 
blindness and death. Recently, "denatured" alcohol has been author- 
ized for commercial purposes and for external medicinal purposes. 
Various substances soluble in alcohol are used to denature or make it 
unfit for drinking. Among these may be mentioned methyl alcohol, 
acetone, pyridine, furfurol, empyreumatic substances and formalde- 
hyde. These compounds are unsuitable for food purposes and there- 
fore alcohol used for preserving foods should be carefully examined 
for denaturants. 

Benzoic Acid. — There is no preservative concerning which there has 
been so much debate as benzoic acid. Benzoic acid is practically 
always used in the form of its water-soluble sodium salt, sodium 
benzoate. 

It is not burned by the animal body into carbon dioxide and water, 



PRESERVATION OF FOODS 335 

as are sugar, alcohol and vinegar, nor is it a normal constituent of the 
body. It is a phenol compound and is excreted as hippuric acid. 
Hippuric acid is excreted normally in small quantities in the urine, 
the body having a special mechanism for this purpose. It is not a 
food in any sense of the word. 

Dr. Harvey W. Wiley's well-known experiments on laboratory 
workers tended to show that small quantities of benzoic acid, given in 
the form of the acid and sodium benzoate, produced digestive dis- 
turbances. 

The Referee Board of Scientific Experts, repeating the Wiley Experi- 
ments, obtained results exactly contrary, and were of the opinion that 
sodium benzoate in quantities not greater than one-tenth of 1 per cent, 
was a harmless preservative for foods. 

Benzoic acid is a white powder insoluble in water, but very soluble 
in ether. Its sodium and potassium salts are very soluble in water 
but insoluble in ether. The water solubility and cheapnes' of the 
sodium salt, together with its preservative action, make it available 
as a food preservative. 

It is a weak preservative and is always fortified by the sterilization 
of the food product if it is intended to hold it for any length of time. 
Its principal use is found in catsup and similar condimental sub- 
stances. It is rarely if ever used now in milk or pickling fluids. 

Method of Separation and Identification of Benzoic Acid. — The sub- 
stance under examination is either made alkaline and filtered and the 
solid residue thoroughly washed or it is acidified with hydrochloric 
acid and treated directly with the solvents. 

The principle involved is that benzoic acid is practically insoluble in 
water, but soluble in ether and chloroform. The salts of this acid are 
insoluble in ether and chloroform but soluble in water. Therefore if 
one adds a little alkali (NaOH or ammonia preferable) to ensure any 
free benzoic acid being converted to its salt and then filters the salt 
will be in the filtrate, free from the solid mass of food material. The 
benzoic acid is then set free with hydrochloric acid and then extracted 
with ether. Or one may add directly to the product under examination 
a stronger acid (HC1) to liberate the benzoic acid from its salts. The 
choice of method depends upon the character of the material submitted 
for examination. In both methods the benzoic acid is finally separated 
by shaking with successive portions of ether in a separatory funnel. 

The ether solution is filtered through dry paper to remove the last 
remnant of water. Ammonia is added to convert any benzoic acid 
present to a non- volatile ammonia salt and the ether is evaporated at a 
low temperature. It may be allowed to evaporate spontaneously at 
room temperature. In such a case the addition of ammonia is unneces- 
sary and the final residue may be weighed. If ammonia is added to 
alkaline reaction, evaporate on the water-bath until all the ammonia 
is driven off. The residue is weighed for quantitative results and 
then tested with a few drops of ferric chloride. Ammonium benzoate 
gives a so-called "flesh colored" precipitate. Usually about 0.1 per 



336 PRESERVATION AND ADULTERATION OF FOOD 

cent, benzoic acid as sodium benzoate, the U. S. Dept. of Ag. limit, is 
used by food manufacturers. 

Volatile Matter in Smoke. — A large number of compounds are 
formed by the destructive action of heat upon wood, among these are: 
phenol, cresol, napthaline, benzol, toluol, methyl alcohol, formic and 
acetic acids, furfurol and many others. There is no doubt that if 
taken alone in concentration these volatile products would cause 
digestive disturbances of more or less severity. As they are applied 
to meat and fish only small amounts affect the tissues, so that any harm- 
ful effect due to the smoke is minimized. It is one of the oldest methods 
of preserving meat and fish, and, possibly for this reason, it has escaped 
the criticism of physiologists. 

These volatile products of destructive distillation of wood are not 
foods. They are purely chemical preservatives, some of which would 
not be tolerated if taken under their true name for food preservation 
and the fact properly made known on the label, as the Federal law 
requires. Here is a large field for an important and practical investi- 
gation in food preservation. 

Spices. — Spices owe their antiseptic value to the different essential 
oils they contain. As already quoted, these oils are real poisons when 
taken in 1;heir concentrated form. Usage again may be said to be 
responsible for the idea that they are real foods because they are 
derived from plants and herbs. They have the property of yielding 
hydrogen peroxide and ozone by slow oxidation in presence of air 
and water. But it is improbable that these compounds contribute 
appreciably to the antiseptic value of spices. 

Spice extracts are used frequently. The powerful flavoring property 
of such extracts is a safeguard against their excessive use. 

Formaldehyde. — Formaldehyde is the first product of oxidation of 
wood alcohol. It is a gas of powerful disinfecting properties, and is 
soluble in water up to about 40 per cent, at ordinary temperatures; 
in such a solution it is known as formalin. It is poisonous, uniting 
with protein to form compounds and alkali in the blood resulting in 
the production of formates. It has a hardening and tanning effect 
upon protein, rendering it insoluble in artificial gastric juice. 

Formaldehyde has been sold and used extensively for the preserva- 
tion of milk under the name of "preservaline." Formaldehyde is so 
powerful in its killing power that 1 part of formalin added to 50,000 
parts of milk will keep it from souring for several days. 

It has been used also as a deodorant for rotten eggs, and is to be 
suspected, wherever its use is applicable, in an investigation for 
preservatives in food. 

The simplest test for detecting formaldehyde is the "Hehner test." 
This is applied to milk. It consists in underlaying a sample of the 
suspected milk with strong sulphuric acid of at least 90 per cent., con- 
taining some iron in solution. At the point of contact of the acid and 
milk a violet ring forms yi a few moments, if formaldehyde is present. 
By this method 1 part to 50,000 is easily detected. It is sensitive up 
to 1 part formaldehyde to 500,000 parts milk. 



PRESERVATION OF FOODS 337 

Salicylic Acid.— Salicylic acid is not a food in any respect, though it 
occurs naturally in small quantities in some of our plant foods. Its 
effect upon the human was investigated by both Dr. Wiley and the 
Referee Board, resulting in the same conclusion that its action on the 
human was deleterious and that it should be condemned as a food 
preservative. 

Salicylic acid is a white powder and is used usually as the soluble 
sodium salt. It exhibits the same properties toward solvents as those 
described for benzoic 'acid and its separation from food is carried out in 
exactly the same manner. The test-solution of ferric chloride, however, 
produces a claret red color, by which it is identified. 

Boric Acid. — Boric acid has been a favorite food preservative. Like 
benzoic and salicylic acid it is found naturally in some foods, as pre- 
viously mentioned, but unlike them it is a mineral acid and not an 
organic acid. It plays no part in the body. Experiments carried out 
under Dr. Park's direction on the feeding of kittens and white mice, in 
the Research Laboratory of the Department of Health of New York 
City, showed conclusively that it is an unfit substance to put into food. 
In these experiments the kittens without exception died, while the 
controls lived. The mice given boric acid in their food did not thrive 
and grow, while the control mice did. 

Subsequently, Dr. Wiley and the Referee Board found in their tests 
upon humans that it produced digestive and other disturbances, and 
condemned it as a food ingredient. 

It has been used in milk and has been allowed in butter, in minute 
quantities, by the English. All foods should be examined for boric 
acid in a systematic search for preservatives. It may be used in the 
form of its salt, borax. 

The method for its identification in food is as follows: The food 
under suspicion is made alkaline, dried, ashed and leached out with 
water. This water solution is then filtered and acidified with hydro- 
chloric acid. A strip of turmeric paper is moistened with this acid 
solution and dried on the steam-bath. In the presence of boric acid 
or borax the paper becomes cherry red, turning bluish green on the 
addition of a drop of dilute ammonia. 

Fluorides.— Fluorine is used as a preservative in the form of a soluble 
salt, usually sodium fluoride. It is exceedingly corrosive, and in larger 
quantities is fatal in a few hours. Recently a fatal accident occurred 
in New York City through the mistaking of a roach powder for Rochelle 
salts. This powder contained 50 per cent, sodium fluoride. 

It has been used at times as preservative of beer and vegetables and 
cannot be condemned too strongly for such purposes. 

Fluorine is separated and identified in the following manner: 

A weighed portion of about 100 gm. of a solid or semisolid food, or a 
measured portion of about 100 c.c. of a liquid food representing a fair 
sample, is mixed with calcium or barium hydroxide until alkaline. 
The mass is brought to dryness and ignited to an ash. This ash con- 
tains all fluorine in the sample examined. It is then transferred to a 
22 



33S PRESERVATION AND ADULTERATION OF FOOD 

small lead dish and treated with concentrated sulphuric acid, after which 
it is covered with a paraffined clock glass that has been marked with a 
sharpened wooden stick, thus exposing a portion of the glass. Fluorin 
by this process is freed from its barium or calcium salt and will attack 
the exposed glass, etching the figures marked by the stick in the 
paraffin. The action of the fluorine on the glass should be allowed 
to proceed for several hours to ensure as good a result as possible. 
After removal of the paraffin, care being taken not to scratch the glass, 
the glass is washed with alcohol thoroughly and dried, so that the 
etching which may be faint may be brought out clearly. 

Fluorine belongs in the halogen group with the well-known elements 
chlorine, bromine and iodine, and has many properties in common with 
them. 

Pyroligneous Acid (Liquid Smoke). — When wood undergoes destruc- 
tive distillation in a closed retort, volatile liquid and solid products 
are obtained. Among the liquid products is pyroligneous acid, a 
substance of varying composition but containing phenol, creosote, and 
empyreumatic substances. It is used improperly as a preservative 
fluid for meats, sausage and fish by simply using it as a dip or applying 
it to the surface of the meat with a brush. It has no food value. It is 
poisonous when taken alone in appreciable quantities. It has no place 
in food preparations. 

Formic Acid and Formates. — These compounds have been found 
occasionally in food products but, being relatively weak preservatives, 
are supplanted by the more efficient ones, such as benzoic and sulphu- 
rous acids. Formic acid is the oxidation product of formaldehyde, and 
is found in the urine of individuals poisoned by wood alcohol, when it 
may be considered as the indicator for wood alcohol in poisoning through 
an alcoholic beverage. Formic acid is found in certain varieties of 
ants in considerable quantities, and the poisoning due to the stings of 
the bee and wasp is attributed to formic acid. 

When applied to the skin it is irritating and has been used in medicine 
as a counter-irritant. It may be considered as a true poison and 
therefore should never be used as a food preservative. It has a strong 
reducing action and probably its preserving action is due to this 
property. 

It is separated from its mixtures after acidifying to free it from its 
salts, by distillation and is identified by applying tests, depending 
upon its reducing power. 

Nitrates. — The nitrates, usually in the form of potassium nitrate, 
known as nitre or saltpetre, are used in pickling fluids. There is a 
difference of opinion regarding their effect on the human whether 
harmless or deleterious. 

Saltpetre has been in use for a considerable time without exhibiting 
any noticeable bad effects, and for that reason it is allowed as a food 
preservative. It is, at best, a weak preservative. 

Peroxides. — Hydrogen peroxide, and the peroxides of magnesium 
and calcium are very effective preservatives. They act through the 



PRESERVATION OF FOODS 339 

liberation of nascent oxygen with the formation of water, in the case 
of hydrogen peroxide, and the hydroxides of calcium and magnesium, 
in the case of peroxides of these metals. 

They appear to be ideal preservatives for foods for which they are 
suitable and offer no objection, except the general objection to all 
chemical preservatives, that of abuse in their application. 

Since peroxides break down so readily into substances that offer 
no means of proving the previous presence of a peroxide, it is extremely 
difficult to detect them. 

Undestroyed peroxides may be detected in food by the following 
method: A sample of 100 gm. is acidified with sulphuric acid and 
distilled. The distillate will contain the hydrogen peroxide if present 
in the sample. The following tests may be applied to identify peroxide 
in this distillate : 

Starch. — A potassium iodide (substituted for zinc iodide) starch 
solution is prepared, made by dissolving potassium iodide in a dilute 
starch solution. This solution when added to milk containing hydrogen 
peroxide gives a blue coloration depending upon the amount of the 
preservative present. 

Paraphenylene Diamine. — This is made by dissolving 2 gm. of 
paraphenylene diamine in 100 c.c. of distilled water. A blue colora- 
tion is formed in milk in the presence of hydrogen peroxide when 
this reagent is added. 

Benzidine. — A 4 per cent, alcoholic solution of benzidine is added to 
10 c.c. of milk, previously made acid with 2 or 3 drops of glacial acetic 
acid, when a blue color is formed in the presence of hydrogen peroxide. 

The experiments made in the Chemical Laboratory of the New York 
Health Department with the paraphenylene diamine reagent have been 
most successful. 

Sulphurous Acid and Sulphites. — Sulphurous acid (S0 2 ) is the first 
product found by burning sulphur in air. It is partially oxidized, 
containing only two oxygen atoms in the acid radical S0 2 . It is, 
readily oxidized to S0 3 , and upon this depends largely its preserving 
property. The propriety of its use as a food preservative has been the 
cause of much controversy, and is still unsettled. 

Dr. Wiley found, through feeding experiments on his squad, that it 
produced digestive disturbances. The report of the Referee Board 
has not yet been published. 

It is used for a great variety of foods, both liquid and solid, such as 
meat and meat products, dried fruits, lime juice, cider, candy and 
molasses. It has the property of not only inhibiting and killing 
microorganisms, but of giving meat a fresh red appearance, and in this 
way covering inferiority. 

It is used in the dried fruit industry not only to kill organisms, 
moulds and insects, but also to enable the manufacturer to add an 
excessive amount of water to the product, and it acts as bleaching agent, 
which improves the appearance of the product. This, of course, is a 
direct fraud. It also has the property of hardening glucose, which is 
used in making clear candy. 



340 PRESERVATION AND ADULTERATION OF FOOD 

" Avisol" is a 30 per cent, solution of sulphurous acid, which has been 
on the market for a number of years and is used by candy manufac- 
turers to give their clear candy greater "dryness" especially in warm 
weather. Analysis shows it to be present in quantities of about 0.01 
per cent, or less in candy prepared with it. 

There is no Federal law at present preventing the use of sulphurous 
acid, providing the food product bears a label declaring its presence. 

Method of Separation. — Concentrated phosphoric acid is added to a 
weighed portion of the sample and the mixture distilled. Sulphur 
dioxide (S0 2 ) is liberated and distilled over into an oxidizing mixture 
of iodine or bromine, where it is converted into sulphuric acid. The 
sulphuric acid is precipitated with barium chloride as barium sulphate, 
filtered, washed, ashed, weighed and S0 2 calculated. 

There are certain other methods that should be touched on in 
discussing food preservation, though they are only partially effective 
and unreliable. Lactic acid, a weak organic acid, produced by the 
fermentation of milk sugar, carbon dioxide, the violet ray and the 
electric current have all been used with more or less success. 

Lactic Acid. — Lactic acid has the property of preventing the growth 
of many putrefactive organisms, and in this way is used as a preserva- 
tive. Lactic acid is produced by the ferementation of milk by certain 
organisms, and products of this type known as koumis, kefir and 
matzoon, and other fermented milk products of the same general type 
are in general use. Some of these contain alcohol. 

Metchnikoff proposed a system of intestinal disinfection based upon 
the presence of lactic acid in fermented milk, attributing the long life 
and good health of certain European mountain tribes to the use of 
this kind of food. 

Lactic acid is also produced in the manufacture of sauerkraut, now 
known in America as "Liberty Cabbage," and is considered one of its 
valuable ingredients. It should be considered, when in proper pro- 
portion, as one of the legitimate food preservatives. 

Violet Ray. — Organisms are killed by the violet ray when directly 
attacked by it. It has not been successfully applied to food, however, 
since particles of various kinds may act as a screen for the organisms. 

Electricity. — The action of the electric current on water is to produce 
nascent oxygen. This method of killing organisms is practically the 
same as that of the addition of peroxides. If salt be present, the 
electrolytic action also produces sodium hypochlorite which possesses 
antiseptic properties. 

Carbon Dioxide. — It has been observed in mineral water that carbon 
dioxide (C0 2 ) exerts a sterilizing action. This property has been 
utilized to some extent for other foods, both by replacing the atmosphere 
entirely or partially by the addition of carbon dioxide. Patents have 
been given for this methoxl of food preservation, but it has not yet come 
into general use. Its action on foods has not been fully determined, 
though it would seem probably that such substances as milk might be 
altered through its action on the protein. 



FOOD ADULTERATION 341 



FOOD ADULTERATION. 



It has been said that an army travels on its stomach, meaning that 
it is necessary to have a proper food supply for the army that it may 
travel and fight . It is equally true that a community or nation depends 
upon its food supply in order to thrive and prosper in its undertakings, 
and this food supply must be of the best quality and in sufficient 
quantity. It is unfortunate that whenever necessity arises there are 
always those who take the opportunity to add to their wealth at the 
expense and perhaps injury of their fellows. This is no more strikingly 
exemplified than in the food industry. It is probable that it has 
always been practised, but it has never been so scientifically practised 
as during the last fifty years. Within this period a more intimate 
knowledge of food properties has been gamed, the studies of chemistry 
and physics have taken tremendous strides and practically all our 
knowledge of bacteriology has been developed. This marvelous 
increase in theoretical and applied learning has been of inestimable 
value in obtaining a larger and improved food supply for the world, 
but it has also given to unscrupulous food manufacturers and food 
dealers a means of degrading the food supply by methods that are 
correspondingly difficult to detect and to punish when detected. 

Through the adulteration of food the quality is usually reduced, 
possibly harmful substances may be added or necessary natural ingre- 
dients reduced or abstracted, and in addition the profit is increased by 
substituting an inferior for a better article. 

One of the most noteworthy steps taken to protect the American 
Food Supply resulted from the work done by the U. S. Department of 
Agriculture' (1886 to 1891) and published as Bulletin Xo. 13, entitled 
"Foods and Their Adulterations," under Dr. H. W. Wiley chief 
chemist. This bulletin, or rather series of bulletins, covered all the 
principal groups of foods sold as human food and exposed the forms of 
sophistication practised. As a result of this publication a bill was 
introduced into Congress, by Mr. Heyburn, designed to prevent food 
sophistication. This bill was defeated, but was followed a few years 
later by another bill based principally upon the Heyburn bill. This 
was passed and became a law. It is popularly known as the Pure 
Food and Drugs Act of June 30, 1906. It is very comprehensive, and 
stands now practically as originally passed. Practically all the States 
of the United States have adopted this law, in whole or in part, so that 
though, as a Federal measure, it only deals with interstate and inter- 
national commerce, its counterparts are efficacious in the various 
States. 

Food adulteration, as defined by the Federal Pure Food and Drugs 
Act, falls naturally into the following groups, where the composition 
of the food itself is considered only : 

"Sec. 7. That for the purposes of this Act an article shall be deemed 
to be adulterated : 

In the case of conf ectionerv : If it contain terra alba, barvtes, talc, 



342 PRESERVATION AND ADULTERATION OF FOOD 

chrome yellow or other mineral substances or poisonous color or flavor, 
or other ingredient deleterious or detrimental to health, or any vinous, 
malt, or spirituous liquor or compound or narcotic drug. 

In the case of food : 

First. — If any substance has been mixed and packed with it so as 
to reduce or lower or injuriously affect its quality or strength. 

Second. — If any substance has been substituted wdiolly or in part 
for the article. 

Third. — If any valuable constituent of the article has been wholly 
or in part abstracted. 

Fourth. — If it be mixed, colored, powdered, coated, or stained in a 
manner whereby damage or inferiority is concealed. 

Fifth.— If it contain any added poisonous or other added deleterious 
ingredients which may render such article injurious to health: Pro- 
vided, That when in the preparation of food products for shipment 
they are preserved by any external application applied in such manner 
that the preservative is necessarily removed mechanically, or by 
maceration in water, or otherwise, and directions for the removal of 
said preservative shall be printed on the covering or the package, the 
provisions of this Act shall be construed as applying only when said 
products are ready for consumption. 

Sixth. — If it consists in w T hole or in part of a filthy, decomposed, or 
putrid animal or vegetable substance, or any portion of an animal 
unfit for food, whether manufactured or not, or if it is the product of 
a diseased animal, or one that has died otherwise than by slaughter." 

The adulteration of which a food may be susceptible depends largely, 
and in many instances entirely, upon its nature. For this reason in 
discussing this question it is convenient to place foods in their natural 
groups from the standpoint of their composition, since each of these 
groups has many properties in common and hence has like forms of 
adulterants peculiar to each. 

This holds true for foods in which these groups exist practically as 
individuals, or completely so, as in oils, sugars and meats, or where 
they are mixed in various proportions, either naturally or as manu- 
factured articles. 

The following are the general groups in which foods are usually 
placed : 

1. Foods of a protein nature or those in which protein is the chief 
factor. 

2. Foods of a carbohydrate nature or those in which starch and 
sugars are the chief factors. 

3. Foods of a fatty nature or those in which fats and oils are the 
chief factors. 

4. Alcoholic and non-alcoholic liquors. 

Beside physical and chemical adulteration, the U. S. Department of 
Agriculture also includes false and misleading statements as to the 
quality and composition of foods in its conception of food adulteration 
as follows: 



FOOD ADULTERATIOX 343 

"Sec. S. — That for the purpose of this Act an article shall also be 
deemed to be misbranded: 

In the case of food : 

First. — If it be an imitation of or offered for sale under the distinctive 
name of another article. 

Stroud. — If it be labeled or branded so as to deceive or mislead the 
purchaser, or purport to be a foreign product when not so, or if the 
contents of the package as originally put up shall have been removed 
in whole or in part and other contents shall have been placed in such 
package, or if it fail to bear a statement on the label of the quantity 
or proportion of any morphine, opium, cocaine, heroin, alpha or beta 
eucaine, chloroform, cannabis indica, chloral hydrate, or acetanilid, 
or any derivative or preparation of any of such substances contained 
therein. 

Third. — If in package form, the quantity of the contents be not 
plainly and conspicuously marked on the outside of the package in 
terms of weight, measure or numeral count: Provided, however- 
That reasonable variations shall be permitted, and tolerances and also 
exemptions as to small packages shall be established by rules and regu- 
lations made in accordance with the provisions of Section 3 of this Act. 
That this Act shall take effect and be in force from and after its passage : 
Provided, however, That no penalty of fine, imprisonment, or confisca- 
tion shall be enforced for any violation of its provision as to domestic- 
products prepared or foreign products imported prior to eighteen 
months after its passage. 

Fourth. — If the package containing it or its label shall bear any 
statement, design, or device regarding the ingredients or the sub- 
stances contained therein, which statement, design, or device shall be 
false or misleading in any particular: Provided, That an article of 
food which does not contain any added poisonous or deleterious ingre- 
dients shall not be deemed to be adulterated or misbranded.''' 

This label clause supplements the previous clauses dealing with 
physical and chemical methods of adulterations, thus expressing clearly 
and without equivocation what the U. S. Government considers forms 
of food adulteration. 

The results following the enforcement of the Pine Food and Drugs 
Act have been so successful that the cases of gross adulteration as 
formerly practised, such as the use of poisonous metallic salts of 
brilliant color for coloring candy, the sale of diseased and putrid meats, 
the sale of rotten eggs to bakers for cakes, and the packing of decayed 
fruits and vegetables, have practically ceased. 

Improved methods and modern sanitary factory conditions, employed 
by the present-day food manufacturer, have brought the American food 
industry up to a very high standard. But notwithstanding the best 
efforts of those mterested in the production of the best food, there are 
always those who wilfully manufacture adulterated food and seek to 
cover it by skilful wording of the label. 

Food adulteration as it now occurs is of a more subtle nature in 



3 1 1 PRESERVATION AND ADULTERATION OF FOOD 

which the labeling and advertising matter accompanying it plays the 
1 principal part. * 

The use of improper material in food manufacture is best discovered 
by inspection at the source, and in some instances can only be dis- 
covered at the source, as, for example, the use of diseased cattle, hogs 
and sheep in the meat-packing industry. When diseased meat is 
trimmed, prepared and processed it is practically impossible to detect 
the lesions of disease. The same statement applies to the fruit and 
vegetable packing industry, the dried and condensed milk industry, 
the jam, jelly and preserve industry, not to speak of the pie, cake and 
bread industries, where practically nothing remains that is character- 
istic of improper ingredients. It requires the combined efforts of the 
food inspector, bacteriologist and chemist to safeguard our daily foods. 

Probably the most important food is milk, since it is the only food 
for infants and the principal food for children and invalids. It is also 
the most general food for all classes and ages. The Federal, State and 
municipal laws covering the production and handling of milk are very 
precise and require that it shall be delivered in the same state as when 
taken from the cow. 

The principal forms of adulteration of milk are extremely simple 
and largely practised. They consist in the removal of cream (skim- 
ming) and by watering. In this way the nutritional value of milk is 
reduced and the composition changed, so that physicians' instructions 
to mothers for modifying infants' milk cannot be accurately carried out. 
Milk must also be watched for the presence of preservatives, which 
usually are formaldehyde and borax. Other preservatives may also 
be found at times. 

There is no food that needs such persistent and careful inspection 
as milk. 

Meats of various kinds are sold in the raw and cooked condition, 
known as processing, or preserved by volatile products in smoke or by 
pickling. The use of diseased animals for food manufacturing pur- 
poses was formerly much more generally practised than at present, but 
even now some animals escape inspection that should be condemned 
for food purposes. It is almost impossible to say whether the meat of 
diseased animals after trimming and processing is harmful to health, 
but as long as there is any doubt the consumer should have the benefit 
of it. There is, too, the aesthetic standpoint which should be considered. 

The chemist may examine meats and meat products for preservatives 
and poisonous metals derived from the containers, and the bacteriolo- 
gist may examine them by appropriate methods for discovering inju- 
rious microorganisms, but neither the chemist nor bacteriologist is as 
effective as the inspector at the slaughter house and in the packing 
house. 

What has been said of the importance of inspection at the source of 
meats holds also for the fish and poultry food industries since all these 
food substances are open to the same general conditions and susceptible 
to the same treatment. Rotten eggs are frozen and by the use of 



FOOD ADULTERATION 345 

formaldehyde deodorized for the food trade. This is a very repugnant 
practice. 

There is no doubt about the danger from eating raw foods that have 
become infected with pathogenic organisms. 

Investigations carried out by the Local Government Board in 
England have shown that practically in every case of illness due to 
protein food living, pathogenic organisms were the cause, and that 
ptomain poisoning due to protein split product almost never occurred. 

Foods of a carbohydrate nature undergo alcoholic, acetic or other 
acid fermentation readily and hence preserve themselves after sufficient 
alcohol or acid is produced. The danger from pathogenic organisms 
from such types of food is very small, but, nevertheless, careful inspec- 
tion is necessary to exclude rotten fruit and vegetables from canning 
or other food products, such as vegetables for chow-chow and catsup 
and pickles and fruit for jams and jellies. The use of such improper 
materials often necessitates the addition of preservatives to hold them 
from fermentation until they can be processed. 

A microscopic examination of the finished product often shows 
enormous numbers of dead organisms, indicating the use of improper 
materials. The Department of Agriculture has put a limit on dead 
organisms as follows: Moulds, 66 per cent, of fields; spores and yeasts, 
125 in -jt-q c.c.; bacteria, 100 million in 1 c.c, and considers foods 
having counts greater than these adulterated. Many Government 
suits are based upon excessive counts successfully. The real objection 
to these foods is that they have been prepared carelessly or from 
unsuitable materials. The dead bacteria and the products of fermen- 
tation are not as a rule deleterious. 

Fats and oils are extremely important food units. They furnish 
energy, save protein, and act as lubricants. In addition, they are 
absolutely necessary to health in a way not understood. This has 
clearly been demonstrated in Germany during the last two years of the 
war, and the attempt to substitute mineral oil as a lubricant was unsuc- 
cessful. The vitamin properties of oils and fats have only recently been 
known and the conditions necessary for healthful fatty products are 
still being studied. Some fats and oils contain a greater quantity of 
vitamins than others. 

Butter is one of the most valuable foods for growing children, as well 
as for adults, on account of its vitamin content. The natural adul- 
terant for butter is some foreign fat. The calorific value may remain 
the same in such mixtures, but the ^dtamin value is cut down and the 
money value is raised. Increased profits through adulteration, as 
pointed out, is practised with all foods, and is the cause for adulteration 
of foods. 

As in the cases of protein foods, starchy and sugar-containing foods, 
a clean, healthy source is desirable and demanded of manufacturers 
and food dealers. Rancid fats and oils may be made salable after 
renovation, that is, by washing out the free acid. Such products 
may be safe foods, but they cannot be considered equal to fats and oils 



3 H> PRESERVATION AND ADULTERATION OF FOOD 

that have not become rancid. Here, too, inspection at the source is 
indispensible in securing a proper product. 

Though the control of food and foodstuffs by inspection at the source, 
with the assistance of the bacteriologist, is of the greatest importance, 
the chemical control of the manufactured product is also very important 
not only to determine whether any injurious metallic substances, color- 
ing matter and preservatives are present, but also to determine whether 
the label tells the truth as to the contents of the products. 

In protein foods, metal dissolved by tissue juices from containers 
may be an important factor, or preservatives not stated on the label 
may be present. 

Incomplete processing may result in decomposition after packing 
and may be identified by chemical processes. Foods of a starchy 
nature, or those with a large proportion of sugar, unless well processed, 
will undergo decomposition, which may be determined by chemical 
methods. Substitution may occur in certain kinds of foods. Honey 
has long been a favorite in this respect, glucose and cane sugar syrup 
being substituted wholly or in part for honey. The vitamin value of 
honey, though small, must be of importance, and this will be decreased 
by the addition of glucose and cane syrup. Maple sugar is another 
favorite for adulteration. Here one finds brown or unpurified cane 
sugar often substituted. When maple sugar sells at 25 cents per 
pound and brown sugar at 6 cents per pound it will be readily seen 
how profitable this adulteration may be. 

Canned fruits and vegetables may contain preservatives to help out 
improper or cheaper methods of manufacturing. 

Alcoholic beverages sometimes are adulterated with wood alcohol. 
This form of adulteration is very dangerous to life and health. Some 
alcoholic beverages are found to be entirely synthetic, though bearing 
a label indicating well-known brands. Creme de menthe is very easily 
adulterated in this way. 

Cider is often watered. It is sometimes made from apple pulp, and 
in many cases has some preservative added. 

Artificial mineral waters are notorious for being adulterated. There 
are but few manufacturers that use formulae that correspond to the 
analyses of the natural waters from which the names are derived. 
Vichy and Seltzer waters often contain only a little salt, whereas the 
original waters are very complex in composition. Such adulterations 
are pure frauds and illustrate the great mass of food adulterations 
found on the market today. 

It might be noted that any apparent relaxation of the food authorities 
is followed by poorer grades of food found on the market. Actual 
harmful food adulteration is seldom found, but deceitful labeling of 
low-grade foods is still not uncommon. 



CHAPTER XII. 

BACTERIAL AND OTHER CONTAMINATIONS OF MILK. 
THEIR RELATION TO PUBLIC HEALTH. 

By WILLIAM H. PARK, M.D. 

Fresh clean milk from the healthy, properly fed cow is thoroughly 
wholesome for children and adults, and while it is not a perfect sub- 
stitute for human milk in infants, it is the best substitute. Milk 
when obtained from a diseased or improperly fed cow, even though fresh 
and clean and free from contagion, is frequently deleterious for infants 
and is sometimes so for adults. When contaminated with excessive 
numbers of the ordinary saprophytic bacteria which have developed 
from those gaining access to it during milking, it is distinctly dangerous 
for infants, especially in hot weather, but usually not appreciably so 
for adults. When it is a vehicle for pathogenic bacteria it brings 
danger to all who consume, it. 

Cities' Milk. — Milk when consumed in towns and cities is never fresh 
from the cow, and rarely delivered directly by the producer to the 
consumer. The farms from which a large city's milk must come are 
pushed further and further away with the increase of population. Thus 
the daily supply of nearly 2,000,000 quarts for New York comes from 
five States. Almost all of it is from a distance of more than fifty miles, 
and a considerable amount is hauled more than three hundred miles. 
The time between the production and the consumption of the milk in 
the larger cities is from twenty-four to sixty hours, and in the smaller 
towns and cities from six to thirty horns. The producer and the 
consumer being unacquainted with each other, there is no possibility 
of the latter knowing from personal inspection how this milk is pro- 
duced. The producer being unacquainted with the consumer has little 
personal interest in him, and feels little or no responsibility as to the 
quality of his milk and has little fear of detection if sickness is produced 
through it. 

The solving of the problem of giving to a people a safe milk requires 
that the conditions at the seat of production, on the transportation 
lines, at the stores and in the houses be correct in all essentials. There 
are few food problems which present as many difficulties as that of the 
giving of a wholesome milk at a reasonable price to consumers who are 
at a distance from the producer. 

People have learned by bitter experience that whenever the milk 
has to be obtained from distant and largely unknown sources there is 
need of responsible control to regulate the methods for the production 



348 BACTERIAL AXD OTHER CONTAMINATIONS OF MILK 

and distribution of milk. The conditions which develop when this 
oversight is lacking were brought to the attention of the public as long 
ago as 1842 in a book published by Robert M. Hartley on the milk 
supply of New York City. He disclosed the appalling fact that the 
greater part of the milk consumed in the city at that time came from 
cows kept in wretched habitations and fed wholly on distillery w T aste. 
The results developing from the use of such milk were very serious in 
the destruction of infant life. 

Young children as well as infants, who consumed this milk, suffered 
seriously in health. The milk secreted by these cows was shown by 
chemical examination to differ markedly from normal milk. The 
effect of the disclosures concerning the harmfulness of this milk brought 
about a widespread reform which prohibited not only the use of distillery 
waste, but also of fermented grains, slops, etc. These measures elimi- 
nated the principal causes of the secretion of deleterious chemical 
substances with the milk. From time to time other foods have been 
discovered which when consumed lead to the production of poisonous 
milk. The feeding of corn before it has blossomed, of improperly 
prepared or rotten ensilage or even good ensilage in amounts beyond a 
daily ration of 30 pounds, of putrefying food, of other improper rations, 
of food infected with ergot, all cause the cow to secrete a milk which 
may cause diarrhea or other illness in young infants. Cows which are 
sick from various diseases will often secrete a milk which is deleterious. 
Harmful chemicals may be added accidentally to milk unless care has 
been taken that the containers for cooling, holding and transporting 
milk have no exposed metals which can be dissolved, such as copper and 
lead. Besides these contaminations of milk, substances are added 
deliberately to it in order to preserve it, to change its appearance or to 
dilute it. 

The addition of germicidal substances to milk is illegal in almost 
every community; yet it must be conceded that some of these in small 
amounts are probably harmless, while others are distinctly poisonous. 
I have watched infants throughout a summer w T hich were fed on one 
part of formaldehyde to twenty thousand parts of milk, and did not 
observe that they suffered in the slightest. Kittens grew to adult size 
on such milk in perfect health, and their tissues w T hen examined under 
the microscope appeared to be perfectly normal. The digestive 
enzymes have been found by investigation not to be interfered with 
by a moderate amount of several other antiseptics. In spite of the 
harmlessness of the addition of small amounts of formaldehyde or of 
certain other bactericidal substances, the practice is universally 
condemned because of the difficulty of controlling the amount and 
varieties used. Fortunately, milk obtained in a cleanly manner and 
kept sufficiently cold reaches the centers of population in good con- 
dition. This necessitates a sufficient supply of ice which may not be 
obtainable in the southern sections of the country. The additions of 
water, gelatin, calcium compounds, etc., to milk and the abstraction 
of cream, although harmless, are properly prohibited because they are 



RELATION OF BACTERIA TO MILK-BORNE DISEASES 349 

done for fraudulent purposes in the endeavor to make a milk appear 
richer than it is. The methods which a city successfully uses to prevent 
these practices is to take samples from time to time and to inflict heavy 
fines, or withdraw the license, when adulteration is detected. 

THE RELATION OF BACTERIA TO MILK-BORNE DISEASES. 

It is only fairly recently that the danger of the usual bacterial con- 
tamination of milk has been understood. Many of the early precau- 
tions, however, which were insisted upon in the care of milk supplies 
by health authorities owed their value to keeping bacteria out of the 
milk or to preventing them from developing in it. 

Milk provides a good soil for growth for a great many varieties of 
bacteria. The ordinary bacteria of the soil and the manure are the 
most commonly found in it, but those from diseased animals and men 
occasionally gain access and remain alive or proliferate and excite 
specific diseases. While some of the saprophytic bacteria produce 
harmful products, others produce those that are harmless. The 
custom in Eastern Europe of drinking milk soured by different lactose 
fermenting bacteria, which has lately been transmitted to Western 
Europe and to us and become almost a fad, strikingly impresses the 
fact that certain varieties of bacteria are not only not harmful to swallow 
to the extent of many billions, but even beneficial. These bacteria 
probably do good by displacing other less desirable bacteria from the 
intestines or by beneficially altering certain food substances during 
their growth and activities. The acidity produced inhibits to some 
extent the growth of human pathogenic bacteria. Unfortunately, 
there are almost always in the air and dust of the ordinary barn, besides 
the wholly harmless varieties, intestinal and other bacteria which 
produce disagreeable and often deleterious substances, so that ordinary 
milk, when soured ("buttermilk"), is frequently dangerous when given 
to young infants. This is especially true if the milk is kept at a 
temperature above 60° F. At a temperature of 80 or higher powerful 
poisons are sometimes produced. Some of these are harmful to adults 
as well as to children. In milk kept at low temperatures, of 50° F. or 
under, products of bacterial growth are usually harmful for infants 
only. 

Even in infants the usual types of bacteria do little harm in cold 
weather; it is only in hot weather, when the resistance of the digestive 
tract is lowered, that these saprophytic bacteria and their products 
cause serious harm. It is true that the actual number of bacteria is 
on the average much higher in the milk in summer, but where infants 
have taken milk of the same quality and containing approximately 
the same number and kinds of bacteria the same marked difference 
occurs in the two seasons. 

As some still attribute the increased diarrhea almost wholly to the 
bacteria, we will consider why the effect of heat on the infant's resist- 
ance and of cows' milk as an imperfect substitute for human milk are 



350 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

equally important factors during the hot months of the year. I once 
had the opportunity of observing the health of the very young children 
in an infant asylum. These children received milk from a nearby farm 
and the bacterial count was always low. During cool weather almost 
no diarrhea occurred. With the Onset of warm weather in June a few 
of the smaller infants developed some illness. During July the cases 
of diarrhea increased, these reached the maximum early in August when 
several deaths took place. With cool weather diarrhea again ceased. 
In this instance, with all factors constant except temperature, disease 
came and went with the hot weather. An actual experiment observed 
by me brought out, on the other hand, the harm that the bacteria in 
the milk produce. 

A group of fifty babies were being fed on a milk pasteurized at 160° 
F. for twenty minutes. Late in June half of these babies were given 
the same supply of milk, but without previous heating. The living 
bacteria in the heated milk averaged about ten thousand per cubic 
centimeter, while the unheated contained about one million. There was 
immediately a marked increase in the diarrhea in the half getting the 
unheated portion of the milk. Some of the infants had to be put back 
on the heated milk before the diarrhea could be controlled. These two 
instances are only examples of the experiences which all investigators 
have had. Heat and humidity predispose the infant to intestinal 
diseases, which cows' milk as such tends to aggravate. While it is 
true that the bacteria in the intestines or those introduced through 
water may under such favorable conditions excite diarrhea, still it 
usually requires in addition the giving of cows' milk with excessive 
numbers of living bacteria or marked chemical changes due to bacterial 
decomposition. 

In order that each reader may satisfy himself of the validity of the 
above conclusions as to the effect of saprophytic bacteria on milk I 
record here a full abstract of the observations made on infants consum- 
ing milk of different degrees of purity. 

BACTERIOLOGICAL INVESTIGATION OF THE MILK USED IN 

FEEDING. 

The clinical work was carried on in conjunction with a bacterio- 
logical study of the milk used, in order to determine whether any 
relationship existed between the number and character of the micro- 
organisms in milk, and the amount of diarrheal disease in the children 
to whom it was fed. Bacterial counts were made once or twice a week 
from the milk as given to each child, specimens being taken at times 
from the raw and at times from the heated milk. 

The bacteria were isolated from the milk through plating in a 2 per 
cent, lactose-litmus-nutrient-gelatin, or agar, and later grown upon 
the usual identification media. The pathogenic properties of the 
different bacteria were tested by intraperitoneal and subcutaneous 
inoculation in guinea-pigs with 2 c.c. of a forty-eight-hour broth culture, 



BACTERIOLOGICAL INVESTIGATION OF MILK 351 

and by feeding young kittens for several days with 3 to 6 c.c. daily of 
twenty-four-hour broth culture by means of a medicine dropper. 

The varieties isolated represent only the species present in greatest 
number in the milk examined, for in no case was more than 0.01 c.c. 
of a milk, and in most highly contaminated milks, only 0.001 c.c. used 
in making a plate, and varieties which occurred in too small numbers 
to be present in this quantity would necessarily be missed. 

During the investigation a number of the varieties isolated from milk 
were shown to be identical with types commonly found in water. 

As a matter of fact, it was found that milk taken from a number of 
cows, in which almost no outside contamination had occurred, and 
plated immediately, contained, as a rule, very few bacteria, and these 
were streptococci, staphylococci and other varieties of bacteria not 
often found in milk sold in New York City; the temperature at which 
milk is kept being less suitable for them than for the bacteria which fall 
into the milk from dust, manure, etc. A number of specimens of fairly 
fresh market milk averaging 200,000 bacteria per c.c. were examined 
immediately, and again after twelve to twenty-four hours. In almost 
every test the three or four predominant varieties of the fresher milk 
remained as the predominant varieties after the period mentioned. 

The above experiments seem to show that organisms which have 
gained a good percentage in the ordinary commercial milk at time of 
sale will be likely to hold the same relative place for as long a period as 
milk is ordinarily kept. After the bacteria pass the 10 or 20 million 
mark, a change occurs, since the increasing acidity inhibits the growth 
of some forms before it does that of others. Thus some varieties of the 
lactic acid bacteria can increase until the acidity is twice as great as 
that which inhibits the growth of streptococci. Before milk reaches 
the curdling point, the bacteria have usually reached over a billion to 
each c.c. For the most part specimens of milk from different localities 
showed a difference in the character of the bacteria present, in the same 
way that the bacteria from hay, feed, etc., varied. Even the intestinal 
contents of cows, the bacteriology of which might be expected to show 
common characteristics contained, beside the predominating colon 
types, other organisms which differed widely in different species and in 
different localities. Cleanliness in handling the milk and the tempera- 
ture at which it had been kept were also found to have had a marked 
influence on the predominant varieties of bacteria present. 

Pathogenic Properties of the Bacteria Isolated. — As bacteria in milk 
are swallowed and not injected under the skin, it seemed wise to test 
the effect of feeding them to very young animals. We therefore fed 
forty-eight-hour cultures of 139 varieties of bacteria to kittens of two 
to ten days of age, by means of a glass tube. The kittens received 5 
to 10 c.c. daily for from three to seven days. Only one culture produced 
illness or death. 

After two years of effort to discover some relation between special 
varieties of bacteria found in milk and the health of children, the 
conclusion has been reached that neither through animal tests nor the 



QW 



\SZ BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

isolation from the milk of sick infants have we been able to establish 
such a relation. Pasteurized or "sterilized" milk is rarely kept longer 
than thirty-six hours, so that varieties of bacteria which after long 
standing develop in such milk do not enter the problem. The harm- 
lessness of cultures given to healthy young kittens does not of course 
prove that the}' would be equally harmless in infants. Even if harm- 
less in robust infants, they might be injurious when summer heat and 
previous disease had lowered the resistance and the digestive power 
of the subjects. 

This failure to discover definite pathogenic bacteria, in more than 
one culture as well as the numerous varieties of bacteria met with, have 
forced us to rely on the clinical observation of infants to note what 
difference, if any, occurred in those fed on raw and pasteurized milk 
from the same source, and upon different milks of unknown origin 
varying in the number of bacteria contained. In the following pages, 
observations upon food are combined with those upon other factors 
which influenced the health of the infants. 

Selection of the Children for Observation. — The original aim was to 
include only infants who were entirely bottle-fed, but it was found that 
the great majority of all infants in the tenements receive during the 
first six months occasionaly breast feedings at night, and nearly all are 
given some solid food after they are six months old, or as soon as they 
are able to hold it in their hands. The purpose of the investigation 
being to obtain relative results with different forms of milk and not 
absolute results with one form, it is believed that the conclusions reached 
are not affected by the fact that many of the infants received breast 
feeding at night. Indeed including such infants has the advantage of 
studying representatives of a very large class. In each season some 
infants who were entirely breast fed were observed for purposes of 
comparison. 

In selecting the children the only conditions made were that they 
should not be ill or suffering from marasmus when observations were 
begun, and that they should be of suitable age. Of the entire number 
340 were six months old or under, 265 were from seven to twelve months; 
47 were a little over twelve months. With the exceptions stated, 
every child available was included by the physicians until the proper 
number was made up. The district in which most of the children lived 
was the lower East Side of New York, as densely populated as any part 
of Manhattan Island. 

The Character of the Food Employed. — It was at first intended to 
make no change in the food the child was receiving, but it was found 
necessary in order that observations might also be made upon the 
comparative effects of heated and unheated milk in summer to place 
a number of infants upon a modified raw milk provided for them 
which was a part of a larger supply distributed to others after pasteur- 
ization. When gastro-intestinal disturbance of any severity devel- 
oped, the infants were deprived of milk for a day or two and put on 
barley water or other suitable food. 



BACTERIOLOGICAL INVESTIGATION OF MILK 



353 



In the district where the observations were made the following 
forms of milk were extensively used: (1) Condensed milk; (2) milk 
purchased at small stores with groceries and other provisions and 
known as "loose raw store milk;" (3) raw bottled milk; (4) pasteur- 
ized milk from central distributing stations. 

Condensed Milk. — That used was usually the sweetened variety. 
It was generally prepared at each feeding by adding hot water which, 
in most cases, had been boiled. 




Fig. 44. 



-Loose milk supply sold in a grocery store. Without a separate milk room 
it is difficult to prevent contamination 



Store Milk'. — It is kept in large cans in the small stores. It averages 
about 3.75 per cent, of fat. It is customary for milk to be purchased 
twice a day and it is carried home and kept in pails or pitchers. In 
summer it is usually heated at once; if it curdles, it is considered to be 
unfit for use and returned. Heating is usually done in a sauce-pan 
and the temperature is raised to a point where the milk begins to 
"foam," seldom to boiling-point. In most cases it is kept upon ice. 
It is usually prepared for the infant at each time of feeding. The 
only modification practiced is, in most cases, dilution with water or 
barley water, equal parts being as a rule given when infants are about 
three months old and continued until ten or eleven months, when whole 
milk is given. 

The bacteriological examination made of this milk during the 
summer of 1901 showed it to contain from 4,000,000 to 200,000,000 
23 



1 



354 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

microorganisms, an average of about 20,000,000 per c.c. The form of 
heating employed killed, it was found, about 95 to 99 per cent, of the 
bacteria present. During the winter the number of bacteria ranged 
from 100,000 to 5,000,000 bacteria per c.c, and averaged about 400,000 
per c.c. Milk of this character has been largely eliminated from 
the larger cities because of pasteurization. 

Bottled Milk. — The greater part of the bottled milk was produced 
under conditions which were only fairly good. However, it was so 
well handled during transportation and delivery that it was nearly 
always in good condition when received by the consumer. This milk 
averaged about 500,000 bacteria per c.c. The same general plan of 
modification was practiced as with the store milk. 

Milk from Central Distributing Stations. — The greater part of this 
milk was supplied from the Infant Milk Depots of which there are a 
number scattered through the city, and a small quantity from diet 
kitchens. The milk used at these places was generally of excellent 
quality, usually from a "certified" farm, but it was mixed with poor 
cream. This milk, after the addition of cream, averaged, before pasteur- 
ization, about 2,000,000 bacteria per c.c; after pasteurization, about 
500 per c.c ; after boiling, about 5 per c.c It is supplied in small bottles, 
each one containing the quantity for a single feeding. The bottles 
are washed and sterilized at the central stations. Some attempt at 
modification was made, three or four standard formulas being used. 
The common modification consisted in the dilution with boiled water, 
the addition of lime water, milk sugar, and, in some cases, cream also; 
or the dilution with barley water and the addition of cane sugar. 
Regarding the use of these formulas, the quantity for one feeding, and 
the number of feedings daily, directions were usually given by the 
physicians in attendance at the Central Stations. As the mothers 
came daily for their milk, some constant supervision of the cases was 
thus possible, and many minor disturbances of digestion no doubt 
controlled by a proper variation in the food. 

Breast Feeding. — As already stated, the great majority of infants 
reared in tenements are breast-fed, at least for the first six months. 
No effort was made to collect many observations upon these children, 
but a few were introduced for the sake of comparison. It was thought 
at first to make a separate division of the children who were partly 
breast-fed, as it was the impression of some of the physicians who fol- 
lowed the cases that a decided difference existed between those who 
were partly nursed, usually at night, and those entirely fed. However, 
the general figures when tabulated did not show any very marked 
difference. The results seem to have depended rather upon the 
character of the other food. 

In estimating the results obtained by the different methods of 
feeding two things were considered: first, the gain or loss in weight, 
and secondly, the amount of digestive disturbance, particularly 
diarrhea, which occurred in the different groups of infants. The cases 
have been divided according to results in four groups : 



BACTERIOLOGICAL INVESTIGATION OF MILK 355 

1. Those which did well. In this group are included the infants 
who made a substantial and generally a regular gain in weight during 
the period of observation, this usually amounting to from two to five 
pounds for the ten or twelve weeks, and those that had no diarrhea 
worth mentioning — usually both conditions existed together. 

2. Those which did fairly, including those in which some diarrheal 
disturbance was present, but not of a serious nor prolonged character, 
and in which the weight was either stationary or the gain very slight. 
Both these generally went together. 

3. Those which did badly, including those in which considerable 
digestive disturbance, usually diarrhea, was present, or in which there 
was a loss in weight; generally here also both factois existed. 

4. The fatal cases. 

The following tables show in a condensed form the results obtained 
with the different foods employed in winter and in summer. 

FOOD AND RESULTS. — 

Did well. Did fairly 

Store milk 47 6 

Condensed milk 39 5 

Good bottled milk .... 51 13 
Milk from Central Distributing 

Stations .35 20 

Best bottled milk 5 

Breast feeding 7 1 

Totals, excluding cases 

counted twice ... 156 41 8 6 211 

FOOD AND RESULTS.— SUMMER. 

Did well. Did fairly. Did badly. 

Store milk 21 23 20 

Condensed milk 22 20 14 

Good bottled milk .... 37 23 29 
Milk from central distributing 

Stations 84 33 24 

Best bottled milk 9 3 

Breastfeeding 17 7 7 



WINTER. 






'. Did badly. 


Died. 


Totals. 


2 





55 


2 


2 


48 


1 


3 


68 


4 





59 


1 





6 





1 


9 



Died. 


Total; 


15 


79 


14 


70 


9 


98 


4 


145 





12 





31 



Totals, excluding cases 

counted twice . .* . 184 108 88 41 421 

Season and Results. — Nothing could be more striking than the 
contrast between the results in winter and in summer. The general 
summary shows that of the 211 winter cases, 156 did well; 41 did fairly, 
8 did badly, and 6 died. In other words, what might be considered 
good results were shown in 93 per cent, of the cases, and bad results 
in only 7 per cent. Furthermore, in only one of the six deaths was the 
cause connected with the digestive tract. 

Of the 421 summer cases, 184 did well, 108 did fairly, 88 did badly and 
41 died. In other words, good results were obtained in 69 per cent, of 
the cases and bad results in 31 per cent., while in nearly all of the fatal 
cases death was due to diarrheal diseases. It should be remembered 



356 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

that ail the children, both winter and summer, had the advantage of 
some continuous intelligent oversight, usually one visit a week and 
often two being made by the physicians. This supervision contributed 
in no small degree to the results in both groups of cases. 

The showing made by the winter cases is most gratifying and was 
indeed a surprise to all. 

To what shall be ascribed the great difference between summer and 
winter results? There seem to be many factors, but a consideration 
of the facts accumulated indicate that heat is the primary factor and 
bacteria and their products a secondary one, except when the contami- 
nation is extreme or pathogenic organisms are present. 

The effect of continued heat upon the health of infants is shown in 
the number of cases of diarrheal diseases and the number of deaths 
during the months of the summer of 1901 in an institution in the 
country near New York City, where a pure milk was fed raw. During 
the winter and spring there was almost no diarrhea; with the warm 
weather of June it increased, reaching its highest point in August. 
The comparative results with the breast and bottle-fed infants are also 
evident. 



Month. No. of infants. 




Food. 


June 34 
25 
38 
128 1 




Breast milk 

Cows' milk 

Breast and cows' milk 

Milk and barley food 


Total . . 225 






Number of cases of diarrhea, 15; deaths 


0. 


July 32 
20 
38 
1241 




Breast milk 

Cows' milk 

Breast and cows' milk 

Milk and barley food 


Total . . 214 






Cases of diarrhea, 38; total deaths, 


3 (all bottle-fed). 


August 28 
18 
32 
129 i 




Breast milk 

Cows' milk 

Breast and cows' milk 

Milk and barley food 



Deaths. 







Total . .207 
Cases of diarrhea, 50; total deaths, 9. 

Food and Results. — 1. Store Milk. — The largest number of bad results 
were seen, as was exacted, with the cheap store milk, where not only 
was the milk poorer, but the care at home less. 

2. Condensed Milk.— The results with condensed milk can hardly be 
attributed to the bacteria, inasmuch as it was almost invariably pre- 
pared with boiled water and contained relatively a small number of 
microorganisms before heating. These children were often apparently 
in good condition until attacked with acute disease, when they offered 



Tho^e <ui milk and barley food were all over twelve months old. 






BACTERIOLOGICAL INVESTIGATION OF MILK 357 

but little resistance and seemed to succumb more quickly than any 
other class of patients. In one family three healthy infants, triplets, 
five months old, were taken sick on the same day with vomiting and 
diarrhea; one died within twenty-four hours, one within two days, and 
the third within a week. A bacteriological examination of the prepared 
milk remaining in one bottle showed nothing noteworthy. 

3. Bottled Milk. — The better results observed with bottled milk 
should not be put down as entirely due to the character of the food. 
The people who purchased it were seldom so poor as those buying store 
milk; they were usually more intelligent and probably more careful 
in handling the milk. 

It is interesting to compare these results with those of store 
milk just preceding them in the table. The percentage mortality 
with the better grade of milk is only about one-half that seen with 
either condensed or store milk, and yet the large number of infants 
who did badly brings the proportion of bad results with bottled milk 
almost up to that with the two preceding varieties. It was noteworthy, 
however, that among infants included as doing badly there was on the 
average less sickness than among those fed on store milk. It would 
seem, therefore, that good bottled milk, as now used, while much less 
dangerous to life than cheap store milk, is still, judging by this propor- 
tion of failures, rather unsuccessful as a method of feeding. 

4. Milk from Central Distributing Stations. — The great difference 
between these results and those obtained with the three forms of feed- 
ing already considered deserves special attention. The original milk 
used at the stations was of good quality, but not much better than 
the bottled milk generally used; with both some form of sterilization 
was practised. The difference in results is not explained by the 
difference in these two factors. There were others of importance 
which must be sought. A certain amount of constant supervision 
was exercised over these infants, as some one, usually the mother, 
came daily to the milk dispensary for the food. Changes could thus 
be readily made in the milk according to the child's condition. If 
symptoms of slight indigestion were present, the mother was instructed 
to dilute the milk; with more severe symptoms, milk was temporarily 
stopped, etc. This supervision seems to us of the greatest value and 
can hardly be secured so well in any other way. Again, a mother 
sufficiently interested in her baby to come or send daily several 
blocks for the milk is generally one who values what she receives 
and also the advice which goes with it. This food, obtained in separate 
bottles for each feeding, is generally regarded by the tenement popula- 
tion as not exactly milk but as something very special, and therefore 
entitled to much more consideration than any form of food which they 
could prepare themselves at home. 

Another point of importance is that some systematic attempt at 
milk modification was made in the milk furnished from central stations. 
Although this could not be done as accurately as for a smaller number 
of patients, the results were certainly improved by it. Again, what 



358 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

contributed in no small degree to success with this plan of feeding, was 
that this milk was supplied in separate bottles for each feeding, that the 
quantity for one feeding was suitable for the child, and that only a 
proper number of feedings for the twenty-four hours was dispensed at 
one time. There was not, therefore, the temptation to over-feeding 
and too frequent feeding, which with other methods are so generally 
practised. Finally, the bottles in which it was kept were always 
properly cleansed and sterilized, since this was attended to at the 
central station. 




Fig. 45. — Cooling, filling into bottles and capping a Grade A milk supply. 



5. Best Bottled Milk. — This was furnished to 18 infants living in the 
tenements, to discover whether any perceptible difference existed 
between the results with this milk and the other varieties. While these 
observations are not numerous enough to admit of any generalizations, 
they indicate what was previously believed, that, with the cleanest 
milk from the best cared for cattle, the smallest number of bad 
results occurred. 

The difference between very bad, highly contaminated milk, like 
that purchased at some of the small stores previous to 1902, and the 



UACTERIOLOGICAL INVESTIGATION OF MILK 350 

best bottled milk, was in some cases very striking. Protracted diarrhea 
in infants who were taking store milk was often immediately improved 
and in several cases promptly cured by simply substituting clean milk 
(after an interval of no milk) for the previous food. In some severe 
cases, however, no improvement followed the purer milk. 

Age and Results. — In 17 cases the ages were not recorded. Of the 
summer cases 217 were infants under six months; 191. were between 
six and twelve months, and 47 were over twelve months. The compara- 
tive results for the different ages are shown in the following table. 

AGE AND RESULTS. — SUMMER. 

Did well, Did fairly, Did badly, Died, 

Age. per cent. per cent. per cent. per cent. 

Under 6 months 52 16 19 13 

7 to 12 months 34 32 26 8 

Over 12 months 49 32 19 

Of the winter cases 123 were infants under six months, and 74 from 
seven to twelve months; none was over twelve months. 

AGE AND RESULTS. — WINTER. 

Did well, Did fairly, Did badly, Died, 

Age. per cent. per cent. per cent. per cent. 

Under 6 months 74 21 5 

7 to 12 months 70 20 10 

Over 12 months 

These figures indicate a considerably higher mortality in infants 
under six months, but a surprisingly large proportion of infants over 
this age who did badly. In summer, other factors than the milk used 
must be taken into account, one of the most important being the 
unwise giving of table food to infants over six months old, a practice 
which is almost universal in the tenement population. Giving fruits 
even to infants is also an important cause of illness. This was strik- 
ingly seen among the Italians. In this class of the population it was 
the opinion of some of the physicians who observed these cases, that 
the use of fruit, often unripe, stale or partly decayed, was the cause of 
more illness in infants and young children than the impure milk. 

A separate study has been made of the cases which did badly, and 
the fatal cases, to determine any other factors beside the food and age 
which contributed to the results. An attempt was made to discover 
what sort of care these infants received, what their surroundings were, 
and whether the results in feeding were due to conditions or diseases 
outside the digestive tract. 

Fatal Cases. — Of the 632 children observed, 47 or 7.5 per cent, died 
during the three months of observation. The mortality of the 211 
winter cases was 2.8 per cent.; of the 421 cases, 11.3 per cent. Of 
infants under one year, neither in the age nor the previous conditions 
do we find any sufficient explanation of the fatal result. In the 47 
observed who were over one year, no deaths occurred. The care which 
the fatal cases received is significant. Only 16 of the 47 infants who 



360 BACTERIM. AND OTHER CONTAMINATIONS OF MILK 

died received good care, and 19 were recorded as positively neglected. 
In 21 of the cases the surroundings were bad. The causes of death in 
the fatal cases were as follows: 

Disease. Summer. Winter. 

Diarrheal diseases 32 1 

Pneumonia 5 2 

Tuberculosis 2 

Rickets .' 1 

Diphtheria 1 

Maramus 1 

Accident 1 

Unknown 1 

41 6 

The winter case having diarrhea was fed upon good bottled milk 
sterilized, and had gastric as well as intestinal symptoms. The 
marasmus case was a child fed upon condensed milk. In only two of 
the winter deaths could the result be definitely connected with the 
feeding; while in summer this was true of 30 of the cases. 

OBSERVATIONS UPON THE FEEDING OF RAW MILK IN OLDER 

CHILDREN. 

The children over three years of age who received unheated milk, 
containing at different times from 145,000 to 350,000,000 bacteria 
per c.c, showed almost no gastro-intestinal disturbance. 

PROPORTION OF INFANTS THAT CONSUME COW'S MILK. 

From investigations it is estimated that during the first nine months 
of life nearly 80 per cent, of infants are entirely or chiefly breast fed. 
From a study of these figures we discover that improvement in the 
milk supply can only affect about 20 per cent, of infants under nine 
months. This is the period during which most deaths occur from 
intestinal diseases. Dr. Cronin tabulated 1000 consecutive deaths 
from enteritis under two years and found 81 per cent, were under nine 
months, 13 per cent, more occurred during the next three months, and 
only 6 per cent, in the second year. 

The danger of cow's milk in infants was brought out by the discovery 
that although more than 75 per cent, of infants are nourished on 
mother's milk, 78 per cent, of the 1000 infants dying of enteritis were 
fed on cow's milk or patent foods. 

General Conclusions. — In addition to the statistical reports of their 
observations, the different physicians who watched the infants in their 
homes were asked to state their own conclusions regarding the general 
problem of infant-feeding in the tenements. These general impressions 
are most suggestive and cannot fail to be of interest to all who are 
working at this difficult problem. 

It was practically the unanimous opinion that the most important 
factor in securing good results is intelligent care. This covers much: 



PROPORTION OF IXFAXTS THAT CONSUME COW'S MILK 3G1 

clean bottles and nipples; the willingness and ability to earn out 
directions as to methods of feeding, quantities, frequency, the stopping 
of milk at the first signs of serious diarrhea, etc. ; proper care of the milk 
itself while in the house, and methods of sterilizing; suitable clothing 
and cleanliness of the children, and as much fresh air as possible. 
An excellent ice-box to keep milk cold was devised by Hess. An 
ordinary box has in its center a piece of tin or linoleum. The space 
between is filled with sawdust. The cover is padded with an inch of 
newspapers. 




Fig. 46. — Hess refrigerator. 



Most of the physicians stated that, leaving out the very worst store 
milk in summer, the results were much less affected by the character 
of the milk than they had anticipated, and distinctly less than by the 
sort of care the infants received. 

The surroundings alone had much less influence on results than was 
anticipated. For not only were breast-fed infants found doing well 
under the most unfavorable surroundings, but those also who received 
only the bottle as a rule did well, provided they received intelligent 
care and good milk. 

The depressing effects of great atmospheric heat, i. e., a temperature 
in the neighborhood of 90° F., or over, were very marked in all infants 
no matter what their food. Those who were ill were almost invariably 
made worse, and many who were previously well became ill. A bad 
method of feeding, or rather a feeding without any method, was 



-' BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

responsible for many failures when the milk itself was of good quality. 
Common mistakes were: feeding an infant every time it cried; giving 
it a full bottle no matter what the age of the child, and letting it take 
as much as it would; preparing a large bottle of food at one time, and 
warming it over from time to time until the child had taken the whole 
of it, or allowing the milk to turn sour in the feeding bottle. Quantities 
proper for single feedings were almost invariably disregarded. Proper 
washing of feeding bottles was seldom seen in a tenement house. Such 
matters as these are closely connected with intelligent care, which has 
been already considered. 

The importance of the matters just mentioned, raises the question 
of how much can be accomplished by the distribution of printed slips 
of directions. It was the observation of the physicians that com- 
paratively little can be accomplished by these alone. Such printed 
circulars are often treated by the tenement-house mother very much as 
most of us treat the printed advertisements which are left at our doors — 
seldom read and soon thrown aw r ay. Mothers are often anxious and 
willing, but ignorant and stupid. Many cannot read and many more 
have not the wit to apply in practice what they read. When, however, 
such printed advice was preceded or accompanied by personal expla- 
nation, it was found of great assistance. Personal contact is the only 
sure way to influence these people, and this must be frequently repeated 
to influence them permanently; as an aid to this, printed slips are useful. 
Printed directions, however, should be as simple as possible in state- 
ment, few in number, and touch only the most vital matters, telling the 
mother always what she is to do, not what she is not to do. 

Summary. — 1. During hot weather when the resistance of the infants 
is lowered, the kind of milk taken influences both the amount of illness 
and the mortality; those who take condensed milk and cheap store 
milk do the worst, and those who receive breast milk, pure bottled 
milk, and modified milk do the best. The effect of bacterial contamina- 
tion is very marked when the milk is taken without previous heating; 
but, unless the contamination is very excessive, it is only slight when 
heating was employed shortly before feeding. 

2. The number of bacteria which may accumulate before milk 
becomes noticeably harmful to the average infant in summer, differs 
with the nature of the bacteria present, the age of the milk, and the 
temperature at which it has been kept. When milk is taken raw, the 
fewer the bacteria present the better are the results. Of the usual 
varieties, over 500,000 bacteria per c.c. are frequently deleterious to 
the average infant. However, many infants take such milk without 
apparently harmful results. Heat above 170° F. (77° C.) not only 
destroys most of the bacteria present, but, apparently, some of their 
poisonous products. No harm from the bacteria previously existing 
in recently heated milk w T as noticed in these observations unless they 
had amounted to millions, but in such numbers they were decidedly 
deleterious. 

3. When milk of average bacterial quality was fed sterilized and raw, 



MEANS TO MAKE SAFE THE MILK SUPPLY 3G3 

those infants who received milk previously heated did, on the average, 
much better in warm weather than those who received it raw. The 
difference was so quickly manifest and so marked that there could be 
no mistaking the meaning of the results. The bacterial content of the 
milk used in the test was somewhat less than in the average milk 
of the city. 

4. No special varieties ot bacteria wxre found in unheated milk w T hich 
seemed to have any special importance in relation to the summer 
diarrheas of children. 

5. After the first twelve months of life, infants are less and less 
affected by the bacteria in milk derived from healthy cattle. Accord- 
ing to these observations, when the milk had been kept cool the bacteria 
did not appear to injure the children over three years of age, at any 
season of the year, unless in very great excess. 

6. Everything possible should be done by Health Boards to improve 
the character of the general milk supply of cities by enforcing proper 
legal restrictions regarding its transportation, delivery, and sale. The 
general practice of heating milk is undoubtedly a large factor in the 
lessened infant mortality during the hot months. 

7. Of the methods of feeding now in vogue that by milk from central 
distributing stations unquestionably possesses the most advantages, 
in that it secures some constant oversight of the child, and since it 
furnishes the food in such a form that it leaves the mother least to do, 
it gives her the smallest opportunity of going wrong. This method of 
feeding is one which might wisely be undertaken by municipalities. 

8. Since what is needed most is intelligent care, all possible means 
should be employed to educate mothers and those caring for infants in 
proper methods of doing this. This, it is believed, can most effectively 
be done by the visits of properly qualified trained nurses or women 
physicians to the homes, supplemented by the use of printed directions. 

9. While it is true that the results with the best bottle-feeding are 
nearly as good as average breast-feeding, it is also true that most of the 
bottle-feeding is at present badly done, so that as a rule the immense 
superiority of breast-feeding obtains. This should, therefore, be 
encouraged by every means, and not discontinued without good and 
sufficient reasons. The time and money required for artificial feeding 
if expended by the tenement mother to secure better food and more 
rest for herself, w T ould often enable her to continue nursing with 
advantage to her child. 

10. The injurious effects of table food to infants under a year old, 
and of fruits to all infants and young children in cities, in hot weather, 
should be much more generally appreciated. 

MEANS THAT CAN BE EMPLOYED TO MAKE THE MILK SUPPLY 
SAFE AND OF FULL FOOD VALUE. 

1. The prevention of adulteration, either by the addition of water, 
the removal of fats, or both, and the exclusion of all preservatives and, 
in fact, all foreign substances. 



364 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

The detection of adulteration requires that samples be taken and 
tested in a chemical laboratory. 

For Adulteration*. The principal adulterations of milk are effected 
by removing some of the cream or by adding water. Either of these 
procedures naturally results in a reduction of the percentage of the fats 
and other solids in the milk. Preservatives are sometimes added to 
prevent souring or rotting. 

There are two general methods for the detection and determination 
of lowered fats and other solids, viz.-, the gravimetric, or weighing 
method, and the mechanical method. 

The Gravimetric Method for Fats. — A definite quantity (5 grams for 
instance) is accurately weighed. It is then absorbed by a roll of fat 
free paper, and dried at not over 100° C, to remove all water. The 
roll then contains all the milk solids. It is next placed in an apparatus 
known as an extractor and there is washed with ether until all the fat 
has been exhausted from the paper and is in the ether. The ether is 
now evaporated, and the fats obtained weighed. 

The Gravimetric Method for Total Solids. — A definite quantity is 
weighed out, as described, in a small dish (lead, platinum, porcelain 
or glass), the weight of which is known, and is evaporated in a steam- 
heated oven to dryness. The weight in excess of the known weight 
of the dish is, of course, due to the milk solids. 

By subtracting the weight of the fats from the weight of the total 
solids we obtain the total solids other than fat, which, of course, repre- 
sents the proteins, the sugar, and the mineral matters. 

The Mechanical Method for Fats. — A definite quantity of milk (17.4 
c.c., about 18 grams) is measured into a graduated bottle, known as a 
Babcock flask, and 17.5 c.c. of strong sulphuric acid (90 per cent.) 
is added. The acid destroys the proteins, which allows the fat to 
rapidly collect in the graduated neck of the flask, when the latter is 
centrifuged. This happens because the fat is the lightest portion of the 
milk, and the heavier matters drive to the bottom of the flask, when it is 
whirled around. The long neck of the flask is so graduated that the 
percentage of fats can be read off directly. This method is accurate 
within two-tenths of 1 per cent., often nearer. 

The Mechanical Method for Total Solids. — The specific gravity of the 
milk is obtained with a lactometer (a graduated instrument which 
floats higher or lower in accordance as the density — weight of a given 
volume — of the milk varies) . From this figure, and the percentage of 
fats, previously obtained, the total milk solids can be calculated and the 
results correspond fairly closely with results obtained by the more 
accurate gravimetric method. 

Preservatives. — Formaldehyde, or borax, or boric acid is sometimes 
used. 

Formaldehyde may be detected by the violet ring that develops 
when a few drops of milk are carefully deposited upon the surface of a 
small quantity of sulphuric acid, containing iron, in a test-tube. 
Boric acid, or borax, may be detected by the following procedure: 






MEANS TO MAKE SAFE THE MILK SUPPLY 



365 



A piece of absorbent paper (filter paper) which has been colored brown 
(by soaking with a solution of a substance known as turmeric) is wet 
with some of the suspected milk. The paper is then dried and a little 
weak ammonia dropped on it. If either borax or boric acid is present 
the brown color of the paper turns green. There are also other tests 
in use. 

2. The production of a clean milk, a milk low in bacteria, involving 
great care from the time of milking to actual consumption. This 
involves effort to insure the cleanliness of the cows and the milkers, 
properly constructed, clean barns, proper and thoroughly cleansed, 
vessels and utensils which the milk comes in contact with, exclusion of 
dust at every stage, immediate reduction of temperature after milking 
thorough icing during transportation, the sale under sanitary conditions 
in stores, and finally, proper care in the hands of the consumer. 




Fig. 47. — -Country inspector's outfit. 

Testing Milk in the Bacteriological Laboratory.— The first requisite 
for the bacteriological examination of milk is that all materials used 
by the sanitary inspectors, or the laboratory force of the Department 
of Health, for handling samples be sterile, i. e., free from bacteria. 
Sterility of these materials is essential, in order that the final result of 
the bacteriological examination may be strictly indicative of the 
number of bacteria per unit of the milk sample examined. 

In the picture is a round can filled with small screw-cap bottles. 
This can with a tin cover which fits tightly, is used by the Department 
of Health inspectors in sending samples of milk from the country to the 
laboratory in the city. The complete country inspector's outfit is 
shown pictured here, prior to being mailed to its destination. Just as 



366 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

soon as the samples have been taken, they are placed in the can, the 
can is packed in ice and reaches the city by express or milk freight within 
a few hours. 

Similar bottles are used by inspectors in the city, but are carried about 
in a hand-grip which has a special compartment for cracked ice. It is 
necessary to keep the samples very cold, for, just as soon as the tempera- 
ture of the milk reaches 50° F., the bacteria present begin to increase. 

When the samples reach the laboratory their temperature is taken 
and recorded; carelessness in the icing of samples thus being detected, 
if it should ever occur; and they are tested at once. The object of the 
test is to determine how many living bacteria are present in one cubic 
centimeter of the sample. This is done by the so-called "plate 
method." The plate or "Petri dish" consists of two glass halves, the 
top fitting well over the bottom. These, after being well cleaned, 
are heated to a temperature of 200° C, in a hot-air oven, for one hour, 
and are thereby rendered dry and free from all living bacteria. The 
plates, ready for use, may be seen along the front edge of the table in 
the illustration. 




Fig. 48. — A photograph of the bacteriological milk laboratory of the New York City 
Health Department. The samples of milk are being plated. 



Undiluted milk is too opaque to be tested by the plate method — 
water is therefore added to the samples. The water used for the 
dilutions is first rendered free of living bacteria by heating at the 
boiling-point for one hour. Some, ready for use, appears in the illus- 
tration, contained in the square bottles with the metal tops, standing 
in front of the Petri dishes on the table. 

The degree to which the milk under examination is diluted depends 
upon the grade of the milk being tested. A poor grade of milk will 
usually have a greater number of bacteria present than a good grade, 
and therefore the sample is diluted to a greater degree in order to 
facilitate the counting, as explained in the following: 



MEANS TO MAKE SAFE THE MILK SUPPLY 367 

The milk sample is shaken vigorously twenty-five times in order to 
break up all clumps of bacteria and to mix them thoroughly with the 
milk. If the sample is of pasteurized milk, a one in one hundred dilu- 
tion is made by adding one part of milk to ninety-nine parts of sterile 
water, and the mixture is shaken vigorously twenty-five times. If the 
sample is of raw milk, two dilutions are made, a one in one hundred 
dilution as described above and, also, a one in ten thousand dilution, 
which is made by adding one part of the one in one hundred dilution 
to ninety-nine parts of sterile water and shaking the mixture twenty-five 
times. 

One cubic centimeter of each dilution of milk is placed in a sterile 
Petri dish. A nutrient fluid, termed beef-extract-agar 1 is added to the 
plate at a temperature of 104° F. and thoroughly mixed with the diluted 
milk. The mixture hardens in the same manner as gelatine when cold, 




Fig. 49. — Photograph of a large number of colonies developing in a layer of nutrient 
agar contained in a small Petri dish. Some colonies are only pin-point in size; some 
as large as the end of a pencil. The colonies here appear in their actual size. (Park 
and Williams.) 

but with the advantage that it does not liquefy in hot weather. The 
plates are later packed in a dark compartment (an incubator) where 
the temperature is constantly maintained at 37.5° C. (body tempera- 
ture) . After forty-eight hours the plates are taken out and examined. It 
will be found that wherever a bacterium lodged at the time the plate was 
made there is now a small spot visible — usually white, but occasionally 
pigmented. Although each spot represents an aggregation of many 
hundreds of 'thousands of bacteria, all in it grew from a single living 
organism, or a tiny clump of organisms, that was present in the sample 
tested, and which was separated from other bacteria by the diluting 

1 Agar, or agar-agar, is prepared from a sea weed found extensively along the shores 
pf the Japanese Islands. 



308 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

and shaking which is part of the routine. It is a simple matter to count 
these spots — technically known as " colonies" — and to multiply the 
total number on the plate by the dilution of the sample. For instance, 
if a plate made from one cubic centimeter of a one in one hundred 
dilution, contains two hundred and fifty colonies, we record the result 
as two hundred and fifty times one hundred, or twenty-five thousand 
bacteria per cubic centimeter of the sample tested. The result gives 
the total number of bacteria per unit (cubic centimeter) of milk, and 
this is an important gauge of its purity and suitability for use as food. 
(See the table of the various grades of milk, and note the maximum 
number of bacteria that each may contain.) The bacteriological 
examination does not reveal the identity of disease producing bacteria. 
To identify these would require an immense amount of work. Suspi- 
cion is aroused by cases occurring in some especial delivery route or 
in the distribution area of a special dealer. The city depends upon 
sanitary control and pasteurization to prevent the spread of infectious 
disease germs. 

3. The production of a milk free from pathogenic organisms, require- 
ing first of all healthy animals, and subsequently, the careful handling 
of the milk at all stages to prevent the introduction of the germs of 
infectious disease through human agencies, flies and dust. 




Fig. 50. 



-Taking samples for bacteriological and chemical tests from cans just taken 
from the train. 



Methods of Public Sanitary Control of the Milk Supply. — The general 
outlines of the methods adopted by boards of health and other govern- 
mental authorities in controlling the sanitary quality of milk supplies 
of towns and cities are fairly well defined. It is recognized that a 
system of inspections of dairies where the milk is actually produced, 
supplemented by inspections of creameries and of pasteurization plants, 
and of the methods of shipment and handling all the way from the 
farmer to the consumer, are necessary elements. Such inspection must 



MEANS TO MAKE SAFE THE MILK SUPPLY 



36.9 



provide for the detection of contagious diseases among those handling 
the milk, as well as for the improvement of sanitary conditions. 

Whether these details are carried out under the supervision of muni- 
cipal or States authorities is a matter of expediency largely governed 
by local conditions. In practice, some of our large cities have found it 
necessary, in the absence of thorough-going State control, to develop 
their own system of milk inspection in the country as well as in the city. 

The control of conditions under which milk is handled and sold 
within the city includes the regular inspection of stores and wagons, 
with frequent chemical and bacteriological tests and the usual method 
of enforcing sanitary requirements by resort to the courts if necessary. 

More particular reference to the present system of milk inspection by 
the Department of Health of New York City and of the methods now 
in use will perhaps illustrate certain phases of the general subject. 

Milk inspection began in New York in the late 70's and this inspection 
work was conducted in cooperation with the State officials of New York 
and New Jersey. Then, however, the elementary forms of adultera- 
tion, consisting in the removal of cream and the addition of water, were 
the only points considered. Later, it developed that a knowledge of the 
bacteriological content of milk was of much greater importance so far 
as the public health was concerned than was its chemical composition. 

Legal Aspects of the New York Plan. — It was under the administra- 
tion of Dr. Darlington, that inspection of milk in the country districts 
was first established and under Health Commissioner Lederle that 
grading and pasteurization was added. The Sanitary Code requires 
that no milk shall be sold in the City of New York without a permit 
from the Board of Health, and the board maintains that it is entitled 
to ascertain the conditions under which milk is produced before issuing 
a permit to the dealer who buys that particular milk and brings it to 
the city. Under the operation of this system, it is rare that permission 
to inspect a dairy or creamery is refused. When such refusal is met with 
the department notifies the dealer who then faces the alternative of 
refusing to receive milk from the particular farm or creamery under 
criticism or of having his permit to sell milk in the city revoked. The 
result, of course, is very salutary in excluding from New York City 
all milk from farms which are known not to meet the requirements. The 
question may be raised as to what protection other communities receive 
under this plan, since the producers whose milk is excluded from New 
York City doubtless find a market elsewhere. This exhibits the great 
defect of local control of milk supplies. It is undoubtedly far better 
that the State should undertake the control of milk production under 
adequate and uniform standards rigidly enforced throughout the State 
by a sufficient number of inspectors. Even if State supervision in 
New York were sufficient, a similar question remains in the case of 
the six other States from which the city's milk is drawn. With these 
varying jurisdictions, the city has been obliged to face actual conditions 
instead of legal or constitutional theories and evolve its own system 
of supervising the milk at every stage from the dairy to the breakfast 
table. 
24 



370 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

The various qualities of milk allowed to be placed on sale 
the Department of Health enforces in connection with the 



REGULATIONS GOVERNING THE GRADES AND DESIGNATION 

NEW YORK. THE FOLLOWING CLASSIFICATIONS APPLY 

BACTERIAL CONTENT AND TIME OF 



Grades of 
milk or cream 
which may be 
sold in the city 
of Now York. 



Definition. 



Tuberculin 
test and 
physical 

condition. 



Bacterial contents. 



Grade A: milk 
or cream 
(raw) 



Grade A milk or cream 
(raw) -is milk or cream 
produced and handled in 
accordance with the min- 
imum requirements, rules 
and regulations as herein 
set forth 



(1) Only such cows 
shall be admitted 
to the herd as 
have not reacted 
to a diagnostic in- 
jection of tuber- 
culin and are in 
good physical con- 
dition; (2) all 
cows shall be test- 
ed annually with 
tuberculin and all 
reacting animals 
shall be excluded 
from the herd 



Milk or cream 
(pasteurized) 



Grade A milk or cream 
(pasteurized) is milk or 
cream handled and sold 
by dealers holding per- 
mits therefor from the 
Board of Health, and 
produced and handled in 
accordance with the re- 
quirements, rules and 
regulations as herein set 
forth 



No tuberculin test 
required but cows 
must be healthy 
as disclosed by 
physical examina- 
tion made annu- 
ally 



Grade A milk (raw) shall 
not contain more than 
60,000 bacteria per c.c. 
and cream more than 
300,000 bacteria per c.c. 
when delivered to the 
consumer or at any time 
prior to such delivery 



Grade A milk (pasteurized) 
shall not contain more 
than 30,000 bacteria per 
c.c. and cream (pasteur- 
ized) more than 150,000 
bacteria per c.c. when 
delivered to the consum- 
er or at any time after 
pasteurization and prior 
to such delivery; no milk 
supply averaging more 
than 200,000 bacteria 
per c.c. shall be pasteur- 
ized for sale under this 
designation 



Grade B: milk 
or cream 
(pasteurized) 



Grade B milk or cream 
(pasteurized) is milk or 
cream produced and 
handled in accordance 
with the minimum re- 
quirements, rules and 
regulations herein set 
forth and which has been 
pasteurized in accord- 
ance with the require- 
ments and rules and reg- 
ulations of the Depart- 
ment of Health for pas- 
teurization 



No tuberculin test 
required but cows 
must be healthy 
as disclosed by 
physical examina- 
tion made annu- 
ally 



No milk under this grade 
shall contain more than 
100,000 bacteria per c.c. 
and no cream shall con- 
tain more than 500,000 
bacteria per c.c. when 
delivered to the consum- 
er or at any time after 
pasteurization and prior 
to such delivery; no milk 
supply averaging more 
than 1,500,000 bacteria 
per c.c. shall be pasteur- 
ized in this city for sale 
under this designation ; 
no milk supply averag- 
ing more than 300,000 
bacteria per c.c. shall be 
pasteurized outside of 
this city for sale under 
this designation 



Grade C: milk 
or cream 
(pasteurized) 
(for cooking : 
and manufac- j 
turing pur- 
poses only) 



Grade C milk or cream is I 
milk or cream not con- j 
forming to the require- 
ments of any of the sub- 
divisions of Grade A or 
Grade B and which has 
been pasteurized accord- 
ing to the requirements 
and rules and regulations 
of the Board of Health 
or boiled for at least two 
(2) minutes 



No tuberculin test 
required but cows 
must be healthy 
as disclosed by 
physical examina- 
tion made annu- 
ally 



No milk of this grade shall 
contain more than 300,- 
000 bacteria per c.c. and 
no cream of this grade 
shall contain more than 
1,500,000 bacteria per 
c.c. after pasteurization 



Note. — Sour milk, buttermilk, sour cream, kumyss, matzoon, zoolac and similar 
"Grade B" and shall be pasteurized before being put through the process of souring. 
\'o other words than those designated herein shall appear on the label of any container 
authorized under State laws. 



MEANS TO MAKE SAFE THE MILK SUPPLY 

have been divided into three kinds and the regulations which 
production of these grades are given in the following table: 

OF MILK AND CREAM WHICH MAY BE SOLD IN THE CITY OF 
TO MILK AND CREAM. THE REGULATIONS REGARDING 
DELIVERY DO NOT APPLY TO SOUR CREAM. 



Necessary 

scores for 

dairies 

producing — 

100 per cent. 

possible. 



Equipment, 25 
Methods, 50 
Total, 75 



Time of 
delivery. 



Bottling. 



Labeling. 



Pasteuri2 
tion. 



Shall be deliv- 
ered within 
thirty-six 
hours after 
production 



Unless other- 
wise specified 
in the permit 
this milk or 
cream shall 
be delivered 
to the con- 
sumer only in 
bottles 



Outer caps of bottles shall 
be white and shall con- 
tain the words Grade A 
raw, in black letters in 
large type, and shall 
state the name and ad- 
dress of the dealer. 



Equipment, 25 
Methods, 43 
Total, 68 



Shall be deliv- 
ered within 
thirty-six 
hours after 
pasteuriza- 
tion 



Unless other- 
wise specified 
in the permit 
this milk or 
cream shall 
be delivered 
to the con- 
sumer only in 
bottles 



Outer caps of bottles shall 
be white and shall con- 
tain the words Grade A 
in black letters in large 
type, date and hours 
between which pasteur- 
ization was completed; 
place where pasteuriza- 
tion was performed ; 
name of the person, firm 
or corporation offering for 
sale, selling or delivering 
same 



Only such milk 
or cream shall 
be regarded 
as pasteurized 
as has been 
subjected to a 
temperature 
of 142-145° 
F. for not less 
than thirty 
minutes. 



Equipment, 20 
Methods, 35 
Total, 55 



Milk shall be 
delivered 
within thirty- 
six hours and 
cream within 
forty-eight 
hours after 
pasteuriza- 
tion 



May be deliv- 
ered in cans 
or bottles 



Outer caps of bottles con- 
taining milk and tags 
affixed to cans contain- 
ing milk or cream shall 
be white and marked 
"Grade B" in bright 
green letters in large 
type, date pasteuriza- 
tion was completed, 
place where pasteuriza- 
tion was performed, 
name of the person, firm 
or corporation offering 
for sale, selling or deli- 
vering same; bottles con- 
taining cream shall be 
labeled with caps marked 
"Grade B" in bright 
green letters, in large 
type and shall give the 
place and date of bott- 
ling and shall give the 
name of person, firm or 
corporation offering for 
sale, selling or delivering 



Only such milk 
or cream shall 
be regarded 
as pasteurized 
as has been 
subjected to a 
temperature 
of 142-145° 
F. for not less 
than thirty 
minutes. 



Score 40 



Shall be deliv- 
ered within 
forty-eight 
hours after 
pasteuriza- 
tion 



May be deliv- 
ered in cans 
only 



Tags affixed to cans shall 
be white and shall be 
marked in red with the 
words "Grade C" in 
large type and "for 
cooking" in plainly vis- 
ible type, and cans shall 
have properly sealed 
metal collars, painted 
red on necks 



Only such milk 
or cream shall 
be regarded 
as pasteurized 
as has been 
subjected to a 
temperature 
of 142-145° 
F. for not less 
than thirty 
minutes. 



products shall not be made from any milk of a less grade than that designated for 
Sour cream shall not contain a less percentage of fats than that designated for cream, 
containing milk or cream or milk or cream products except the word "certified" when 



372 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

As may be well imagined, the attempt of New York City to exercise 
authority over the milk production of other States was not allowed to 
go unchallenged and the whole question was carried through the courts 
in appeal after appeal until finally the Supreme Court of the United 
States in a unanimous opinion affirmed that the position of the City 
of Xew York was reasonable, valid and not unconstitutional. In its 
decision the Supreme Court stated that any State has a right by reason 
of regulations to protect the public health and safety and that the 
Supreme Court "will not interfere because the States have seen fit to 
give administrative discretion to local boards to grant or withhold licenses 
or permits to carry on trades or occupations, or perform acts which are 
properly the subject of regulation in the exercise of the reserved power 
of the State to protect the health and safety of its people." Here 
then w T e have the support of the highest court in the land behind the 
effort to procure proper sanitary control of our local milk supply. 

It is now a well-known fact that the general milk supply of every 
large city in the world is unfit for use in infant feeding. Two well- 
defined methods have been applied in New York to aft'ect a change in 
this respect; first, the production of a special grade of milk, "certified" 
and allied grades, for infants, and, secondly, the general movement to 
improve the whole supply. Each of these methods has been successful 
to only a very limited extent. After twenty years less than 1 per cent, 
of the city's milk is of the certified type or equivalent thereto and the 
expense of this class of milk is almost prohibitive for general use in 
infant feeding. In fact, it is a luxury within reach of comparatively 
few. What is needed is a safe milk which can be furnished at a price 
within the means of the masses. 

Mechanical Milker. — On account of the scarcity of labor the mechan- 
ical milker has become extensively employed. There is no objection 
to its use if the parts are kept scrupulously clean. 

The attempt to bring the general market milk to the degree of purity 
required for infant feeding can never be successful in a large city. In 
the first place it is economically not feasible since to 3 great a part of the 
total supply of milk is used for other purposes, for adults who do not 
require a milk of such special requirements and for cooking purposes 
where a still less degree of bacteriological cleanliness is necessary. It 
naturally follows that milk for the last two mentioned purposes can be 
produced and sold at lower prices than the special infant's milk. In the 
second place, although the system of surveillance has materially lessened 
the danger of infection of milk from the presence of cases of infectious 
diseases among the employees on the farms and in the creameries or 
from unhealthy animals, our present knowledge of the propagation of 
typhoid fever by milk infected by "typhoid carriers," and the fact that 
tuberculosis is so widespread among our dairy herds, have forced us to 
the conclusion that no matter how complete or well organized the 
system of dairy inspection, it will not be possible to render entirely safe 
the ordinary commercial milk which is produced and shipped to a city. 

Dirt Testers. The amount of insoluble dirt can be tested by filtering 
a pint of milk through cotton disks placed at the lower opening. 



MEANS m MAKE SAFE THE MILK SUPPLY 



~ 




p I(i 5i — Mechanical milker, a great labor saving device, but a very difficult apparatus 
to keep clean on account of the valves and tubes. 




Fig. .')2. — Dirt tester, placed over an empty milk can. in operation. 



374 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

The only way in which the sanitary authorities can meet these 
conditions is by requiring the pasteurization at least of all milk that is 
not of the highest grade. 




Fig. 53. 



-Disks of cotton removed from dirt tester showing dirt removed from one pint 
of milk obtained from different sources. 



Early in 1902 the Board of Health of the City of New York officially 
adopted a plan for grading milk according to its sanitary quality. 
The New York Committee on Milk Standards helped the general 
adoption of grading throughout the country. 

Advantages of Grading for the Farmer. — It means in effect that farms 
will be scored, and a farmer will know what grade of milk he is produc- 
ing and how he can produce a better grade if he so desires. The better 
grades of milk will command a higher price at the farm; therefore, for 
the first time in the history of milk production, an incentive will be 
given the farmer to produce a cleaner milk. This principle, of course, 
was established on a very small scale in the production of certified milk, 
but never before in production of milk for the masses. 

For the Dealer. — The grading and proper labeling regulations will 
be a great incentive to the progressive and honest dealer who is willing 
and anxious to sell his products on a proper basis, and who by this plan 
will be aided in his efforts by official control. It will no longer be 
possible for the dishonest dealer to market the lowest grade of milk 
under false representations or to sell cooking milk for infants. 

For the Public. — The users of milk will be enabled to purchase the 
quality of milk they require and for which they can afford to pay. 
This is particularly important in the case of milk for infants and 
children. 

Certified Milk. — Most large cities now provide for infants a special 
milk which has not only the city's supervision but also that of a private 
commission. This milk, called "certified milk," is produced under 
the best attainable conditions. Suitable buildings, healthy tuberculin- 
tested cattle, healthy men, sterile utensils, the utmost cleanliness and 
many other requirements are insisted upon and made certain of by 
frequent inspections and milk examinations. This milk is practically 
a safe infant milk, although even this milk is liable through accident 
to possible contamination. This milk is generally produced under 
the auspices of a Medical Milk Commission. Since Dr. Coit brought 
together the first Commission, many others have been started. The 
Health Department of New York City has always cooperated with 



MEANS TO MAKE SAFE THE MILK SUPPLY 375 

the New York Milk Commissions. Certified milk belongs to Grade A 
raw. The State Agricultural Departments usually aid in making the 
tuberculin tests and in paying for the slaughtered reacting cattle. 

The requirements for production by the New York County Milk 
Commission are as follows: 

A maximum of 10,000 germs as an average per cubic centimeter of 
milk. This standard must be attained solely by measures directed 
toward scrupulous cleanliness, proper cooling and prompt delivery. 

The milk certified by the Commission must contain not less than 4 
per cent, of butter fat on the average, and have all other characteristics 
of pure, wholesome milk. 

Milk must not be sold as certified beyond the day on which it reaches 
New York City. Xo milk may be shipped as certified which will 
reach the City more than thirty-six hours after production. 

The sealed cap, authorized by the Commission, must be used on all 
the certified milk passing through the hands of dealers selling milk 
other than the certified. These caps are sent by the makers only to the 
farm where the milk is bottled. 

The name of the farm from which the milk comes must appear on 
both the paper cap and the sealed cap. 

Each bottle of milk must be dated on the date of bottling, or date to 
be sold. 

The Milk Commission looks to the dealers for its fee. 

Each dealer is expected to send a bottle of milk each week to the 
laboratory, taken at random from the day's supply for examination by 
experts for the Commission. Any dealer shipping to more than one 
town or city must supply weekly from each town. 

The dealers are to furnish deep, covered boxes for certified milk. 

The required conditions are as follows : 

1. The Barnyard. — The barnyard should be free from manure and 
well drained, so that it may not harbor stagnant water. The manure 
which collects each day should not be piled close to the barn, but should 
be taken several hundred feet away. If these rules are observed, not 
only will the barnyard be free from objectionable smell, which is an 
injury to the milk, but the number of flies in summer will be 
considerably diminished. 

These flies are an element of danger, for they are fond of both filth 
and milk, and are liable to get into the milk after having soiled their 
bodies and legs in recently visited filth, thus carrying it into the milk. 

Flies also irritate cows, and by making them nervous reduce the 
amount of their milk. 

2. The Stable. — In the stable the principles of cleanliness must be 
strictly observed. The room in which the cows are milked should have 
no storage loft above it; wliere this is not feasible the floor of the loft 
should be tight, to prevent the sifting of dust into the stable beneath. 

The stables should be well ventilated, lighted and drained, and should 
have tight floors, preferably of cement, never of dirt. 
They should be whitewashed inside at least twice a year, unless the 



376 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

walls are painted or of smooth cement finish which can be washed 
frequently. 

The air should always be fresh and without bad odor Sufficient 
light should be provided to enable the necessary work to be properly 

done during the dark hours. The manure should be removed twice 
daily, except when the cows are outside in the fields the entire time 
between the morning and afternoon milkings. The manure gutter 
must be kept in a sanitary condition. All sweeping of dry floors must 
be completed before grooming of cows is begun. All sweeping must be 
completed before the last washing of udders is begun. 

There should be an adequate supply of water, warm and cold, and the 
necessary wash-basins, soap and towels. 

3. Water Supply. — The whole premises used for dairy purposes, as 
well as the barn, must have a supply of water absolutely free from any 
danger of pollution with animal matter and sufficiently abundant for 
all purposes and easy of access. 

-i. The Cows. — Xo cows will be allowed in the herd furnishing certi- 
fied milk except those which have successfully passed a tuberculin test. 
All must be tested at least once a year, by a veterinarian approved by 
the Milk Commission. All tuberculin tests must be arranged through 
the Milk Commission, or with the approval of the Milk Commission, 
and must be so planned that the representative of the Milk Commission 
may be present throughout, and be accommodated at or near the farm, 
in the same way as the doctor who makes the test, if the Commission 
so desires. 

The farmer for whom the test is made must make sure that a chart 
of each test is furnished to the Milk Commission to keep on file within 
a week after the test, whether it be a private or State test. The Milk 
Commission reserves the right to decide what cows shall be kept in the 
herd. 

Xo test will be regarded as satisfactory to the Milk Commission, 
unless four initial temperatures two hours apart are taken, and the 
temperatures begun after injection at the sixth hour and continued 
every two hours through the twenty-fourth hour after injection. 

Any animal suspected of being in bad health must be promptly 
removed from the herd and her milk rejected. Xo cow whose udder is 
imperfect shall be allowed in the certified herd, nor shall the milk from 
an udder in any way diseased be put in the certified milk, as long as any 
disease exists. Cows must not be excited by hard driving, abuse, loud 
talking nor any unnecessary disturbance. 

Feed. — Xo strongly flavored food, like garlic, should be allowed 
where cows can eat it. 

When ensilage is fed, it must be given in one feeding daily, and that 
after the morning milking only, unless permission to feed half at night 
be given on the condition that all remaining be swept out of the barn 
before barn is closed for the night. The full ration of ensilage shall 
consist of not more than 20 pounds daily for the cow of average size. 
When fed in the Fall small amounts must be given and the increase to 
full ration must be gradual. 



MEANS TO MAKE SAFE THE MILK SUPPLY 377 

Corn stalks must not be U>(\ until after the corn lias blossomed, and 

the first feedings must be in small amounts and the increase must be 
gradual. 

If fed otherwise, ensilage and corn stalks are liable to cause the milk 
to affect children seriously. 

Cleaning. — The entire body of the cow must be groomed daily. 
Before each milking, the udder should be washed with a cloth used 
only for the udders, and wiped with a clean, dry towel. The udder 
must never be left wet, and the water and towel used must be clean. 

The body of cow, from the shoulders back, should be dampened with 
clean water, and brush or towel used for that purpose. The tail should 
be kept clean by frequent washing, and like the body, should be damp- 
ened before each milking. 

If the hair on flanks, tail, and udder is clipped close, and the brush 
on tail cut short, it will be much easier to keep cow clean. 

The cows must all be kept standing after cleaning until the milking 
is finished. This may be done by a chain or a rope under the necks. 

5. The Milkers. — The milker must be personally clean. He should 
neither have nor come in contact with any contagious disease while 
employed in handling the milk. In case of any illness in the person or 
family of any employe in the dairy, such employe must absent himself 
from the dairy until a physician certifies that it is safe for him to 
return. 

A specimen of blood will be taken from each person connected with 
handling the milk and examined for typhoid. Xo person who has had 
typhoid, or reacts to the 'Widal test will be allowed to do any work in 
connection with the production of certified milk. 

In order that the Milk Commission may be informed as to the health 
of the employes at the certified farms, the Commission has had postal 
cards printed, to be supplied to the farms, and to be filled out and 
returned each week, by the owner, manager, or physician of the farm, 
certifying that none are handling the milk who are in contact with any 
contagious disease. 

Before milking, the hands should be washed in warm water, with 
soap and nail brush, and well dried with a clean towel. On no account 
should hands be wet during milking. 

The milkers should have light colored, washable suits, including caps, 
and not less than two clean suits weekly. The garments should be 
kept in a clean place, protected from dust, when not in use. 

Iron milking stools are recommended, and they should be kept clean. 

Milkers should do their work quietly and at the same hour morning 
and evening. 

Jerking the teat increases materially the bacterial contamination of 
the milk and should be forbidden. 

6. Helpers Other Thax Milkers. — All persons engaged in the 
stable and dairy should be reliable and intelligent. Children under 
twelve should not be allowed in the stable or dairy building during 
milking, since in their ignorance they may do harm, and from their 



378 BACTERIAL AND OTHER COXTAMIXATIOXS OF MILK 



liability to contagious diseases, they are more apt than older people to 
transmit them through the milk. 

7. Small Animals. — Cats and dogs must be excluded from the 
stables during the time of milking, and fowl at all times. No animals 
are allowed in the dairy. 

8. The Milk. — All milk from cows sixty days before and ten days 
after calving must be rejected. 

The first few streams from each teat should be discarded in order to 
free the milk ducts from the milk that has remained in them for some 
time and in which the bacteria are sure to have multiplied greatly. 
If any part of the milk is bloody or stringy or unnatural in appearance, 
the whole quantity yielded by that animal must be rejected. If any 
accident occurs in which a pail becomes dirty, or the milk in the pail 
becomes dirty, the pail should be put aside, and the milk must be 
discarded. 

The milk from each cow T should be removed from the stable immedi- 
ately after it is obtained to a separate, clean room, and strained through 
a sterilized strainer of cheesecloth or cheesecloth and absorbent cotton. 

The rapid cooling of the milk is a matter of great importance. The 
milk should be cooled to 45° F. within an hour and not allowed to rise 
above the temperature as long as it is in the hands of producer or 
dealer. In order to assist in the rapid cooling, the bottles should be 
cold before the milk is put into them. 

Aeration of milk beyond that obtained in milking is unnecessary. 

9. Utensils. — All utensils should be as simple in construction as 
possible, and so made that they may be thoroughly sterilized before 
each using. 

Coolers, if used, should be sterilized in a closed sterilizer, unless a 
very high temperature can be obtained by steam sent through them. 

Bottling machines should be made entirely of metal with no rubber 
about them, and should be sterilized in closed sterilizer before each 
milking or bottling. 

If cans are used, all should have smoothly soldered joints, with no 
places to collect dirt. 

Pails should have openings not exceeding 8 inches in diameter and 
may be either straight pails, or the usual shape with top protected by a 
hood. 

Bottles should be of the kind knowm as "common sense," and capped 
with a sterilized paraffined paper disc, and the caps authorized by the 
Commission. 

All dairy utensils, including the bottles, must be thoroughly cleansed 
and sterilized. This can be done by first rinsing in warm water, then 
washing with a brush and soap and other alkaline cleansing material 
and hot water, and thoroughly rinsing. After this cleansing they 
should be sterilized by boiling, or in a closed sterilizer with steam, and 
then kept inverted in a place free from dust. 

10. The Dairy. — The room or rooms where the utensils are washed 
and sterilized and the milk bottled should be at a distance from the 



MEANS TO MAKE SAFE THE MILK SUPPLY 379 

house and the barn, so as to lessen the danger of transmitting through 
the milk any disease which may occur in the house. 

The bottling room, where the milk is exposed, should be so situated 
that the doors may be entirely closed during the bottling and not 
opened to admit the milk nor to take out filled bottles. 

The empty shipping cases should not be allowed to enter the bottling 
room nor should the washing of any utensils, except fixed cooler, be 
allowed in the room. 

The workers in the dairy shouldjwear white washable suits, including 
cap, when handling the milk. n$ m 

Bottles must be capped with the sterilized discs as soon as possible 
after filling. 




Fig. 54. — A steam sterilizer for a small plant. 

11. Examination of Milk and Dairy Inspection. — In order that 
the dealer and the Commission may be kept informed of the character 
of the milk, specimens taken at random will be examined weekly by 
experts for the Commission. 

The Commission reserves the right to make inspections of 
certified farms at any time and to take specimens of the milk 
for examination and to impose fines for repeated or deliberate 
violations of the requirements of the commission. 

The Commission also reserves the right to change its standards in any 
reasonable manner upon due notice being given the dealers. 

When we consider our inability to identify the chronic typhoid 
bacillus carrier, the slight cases of diphtheria and of scarlet fever, 
and the impossibility of eliminating in the near future tuberculosis 
from the dairy herds, we realize that something beyond inspections 



380 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 



is required to make safe the general milk supply. Most of us who 
have studied the question believe that proper pasteurization under 
rigid inspection is the method by which a safe wholesome milk supply 
can be provided. 

Reasons for and Against Pasteurization. — Those who oppose pasteur- 
ization usually do so from one of two standpoints: Some feel that 
the heating of the milk improves its keeping qualities so much that the 
dairyman will cease to take any pains to provide a clean milk or care 
for its preservation. This is not an objection that serious people 
should give weight to. The milk problem is too important to allow T 
difficulties which can readily be obviated to prevent us doing what is 
thought to be best. We know that dirty milk teeming w T ith bacteria 
is not as wholesome after heating as fairly clean milk containing but 
moderate numbers of bacteria. Health authorities must insist on as 
sanitary conditions at the farms and creameries as they consider 
necessary to produce a wholesome milk supply. The average farmer 
does not now T and probably never will take sufficient precautions to 
insure a safe milk. 

The other objection is that pasteurization changes the milk chemically 
so that it is less suitable as a food. Here we must carefully separate 
the milk for infant feeding from that for older children and adults. 
So far as I know there is no serious claim that milk is injured for the 
latter by heating to 145° F. for twenty minutes. For infants there is a 
difference of opinion among experienced physicians. From personal 
knowledge, I can state that very few r infants in New r York City con- 
sume raw T milk. 

There is an opinion held by many intelligent persons that heating 
milk makes it more liable to infection and that the bacteria grow more 
rapidly in it than in its unheated state. This idea has developed from 
the fact that milk w T hen drawm from the udder has slight bactericidal 
properties which cause a reduction during the first few r hours of the 
bacteria in very clean milk. This pow r er is, however, completely lost 
by the time the milk reaches the pasteurizing plant. 

It is also true that if a few T bacteria of a new T variety are added 
to a milk containing only a few hundred bacteria per c.c. they will 
grow faster than if added to milk containing several millions. This 
is merely because the milk is already becoming overcrow r ded with 
microorganisms. When the bacterial growth became still more 
excessive there would be a still greater impediment to the growth of 
new additions. The following outcome of a test wdth five samples, 
which is an average result, shows the absurdity of thinking that the 
bacteria in the heated portion of a milk sample w r ill be able to grow r 
so rapidly as to outstrip the number in the unheated portion. Only 
after the raw milk has become sour will this become possible. 

Temperature at Which Milk Should be Pasteurized. — Those who are 
cognizant of the literature concerning the heating of milk know that 
there has been much difference of opinion as to the temperature which 
should be used. There are manv reasons for these different views. The 



MEANS TO MAKE SAFE THE MILK SUPPLY 



381 



purpose for which the milk is to be pasteurized is not always the same. 
In one case it may be simply to prevent the milk souring at an early 
time. In another it is the destruction of some special variety of 
pathogenic bacteria, as in case of a typhoid infection, and in still a 
third, it is the destruction of tubercle bacilli, which are somewhat more 
resistant than other non-sporebearing pathogenic bacteria. Finally 
where milk is to be kept warm, it may be desirable to actually sterilize 
the milk. 





Sample 1. 


Sample 2. 


Sample 3. 


Sample 4. 


Sample 5. 


Pure milk, origin- 












al number bac. 


2,340,000 


1,440,000 


5,400,000 


118,000 


1,020,000 


Same after heat- 












ing 160° F.: 












one-half min. . 


27,000 


10,000 


1,600 


950 


720 


Same after heat- 












ing for one min. 


10,000 
Kept 24 hou 


1,160 
rs at 48° F. 


900 


450 


260 


Unheated 


8,100,000 


10,800,000 


7,560,000 


660,000 


8,100,000 


One-half min. 


32,400 


12,400 


6,000 


1,680 


1,750 


One min. 


16,500 
Kept 48 hou 


3,400 
rsat 48° F. 


5,000 


1,000 


1,040 


Unheated 


27,000,000 


32,400,000 








One-half min. 


51,000 


15,500 








One min. 


30,000 
Kept 5 hou 


17,000 
rsat 72° F. 








Unheated 


54,000,000 


90,000,000 








One-half min. 


372,000 


116,000 








One min. 


180,000 
Kept 24 hou 


120,000 
rsat 72° F. 








Unheated 


163,000,000 


324,000,000 


108,000,000 


118,000,000 


112,000,000 


One-half min. 


18,900,000 


27,000,000 


8,640,000 


7,560,000 


7,020,000 


One min. 


16,200,000 


21,600,000 


8,100,000 


5,400,000 


5,400,000 



A study of the figures shows that in the ice-chest there is a less increase in the heated 
than in the raw milk. At much higher temperatures there is a greater development, 
but here it is because the bacteria are approaching the limit of their growth and are 
being injured by the acids and other bacterial products produced. One objection is 
true. Pasteurized milk because most of the lactic acid bacteria have been killed, 
will not as quickly sour from bacterial growth. If this were really a serious objection 
it would be a very simple matter to add to the heated milk a few harmless lactose 
fermenting bacteria. 



The methods by which the tests of efficiency have been carried out 
have varied. In some the heat has been applied instantaneously, 
in others it has taken several minutes for it to reach the maximum 
temperature. Still again, early workers were sometimes deceived as 
to the results in tests with tubercle bacilli. Tubercle bacilli when 
dead are now known to poison the tissue cells lying adjacent to them 
and to give lesions showing microscopical appearances similar to those 
excited by living bacilli; when many are injected in one place a small 
abscess may develop. The tissues in which the dead bacilli have 
lodged at the time of injection have thus simulated tuberculosis, and 
caused investigators to report falsely that they were not killed. At 
times the only way that the action of living bacilli can be separated 



382 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

from dead bacilli is to reinoculate a second animal from the first 
doubtful one. 

Considering the results from the investigations of others and of 
those made in the Research Laboratory of the Department of Health, 
the following temperatures may be considered sufficient to destroy all 
pathogenic bacteria apt to occur in milk. If we w T ish to insure the 
destruction of tubercle bacilli, milk heated at 80° C. for one minute, 
75° for two minutes, 70° for three minutes, 65° for fifteen minutes, 
and 60° for twenty minutes, will contain no living tubercle bacilli, and 
necessarily no living typhoid, diphtheria or other non-sporebearing 
human pathogenic bacteria. If it is not necessary to destroy tubercle 
bacilli, those temperatures for one-half the above duration will suffice. 
In order to have the least chemical change in the milk, 60° C. (140° F.) 
for twenty minutes or 65° C. for fifteen minutes, are probably the best 
temperatures to be selected. 70° C. (158° F.) for three minutes is 
also a fairly suitable temperature, especially when the milk is to be 
used by others than infants, for the chemical changes which become 
somewhat greater with the higher temperatures, even for the shorter 
time, are not objectionable when the milk is for adults or older children. 

The figures previously given, which show the destruction of bacteria 
when the milk has been heated for thirty seconds at 60° C, may 
seem to many to show a very surprisingly high death-rate of the bac- 
teria, because the samples of commercially pasteurized milk taken from 
various places and said to be equally heated usually show very much 
less bacterial destruction. It is the practice, however, of commercial 
firms to state that the milk has been heated for a certain number of 
seconds to a certain degree, when, as a matter of fact, the milk has 
only been heated for one or two seconds to the degree stated, the rest 
of the time being occupied in the process of heating and cooling. As 
a rule, also, these pasteurizers have no accurate method of determin- 
ing and regulating the temperature, so that frequently the milk is not 
accurately heated even for a second to the degree stated. In some cases 
because of lack of cleanliness more bacteria are added to the milk after 
heating than were killed in the process. To a certain extent different 
milks will always vary in the percentage of destruction of their con- 
tained bacteria, taking place when they are heated, because of variation 
of the types of bacteria present in the milk. This, however, is only 
true to a very moderate degree. Commercial pasteurization should 
not be allowed to be carried on without careful supervision. There 
should be a requirement that all machines be subjected to tests by the 
health authorities, before they are allowed to be used. After it is in 
operation the inspectors should continue to observe and make sure the 
machines are properly run. All pasteurizers should have some appa- 
ratus which will automatically indicate the temperature to which milk 
is heated, the temperature at which it is cooled, and the rate of flow. 
The records should be at all times subject to examination. 

Dry Milk. — This is prepared chiefly by two processes. In one the 
milk is dried while in a spray. In the other it dries as a film on hot. 



MEANS TO MAKE SAFE THE MILK SUPPLY 



383 



rollers. In the former process the albumins remain partially soluble. 
When prepared from milk of good quality dry milk has about the 
same value as pasteurized milk. The vitamins are partly destroyed 
by heating, and partly by long storing. It may be prepared from 
skimmed milk or from milk containing less than the normal fat-content. 
The use of dry milk is rapidly increasing. 




Fig. 55. — Large pasteurization plant. Milk is heated, held in tanks at 140° F. for 
twenty minutes, cooled and collected into bottles. It is protected from contamination 
as it flows by gravity step by step. 



The Bacteriological Examination of Milk. — The identification of 
pathogenic bacteria in milk is extremely difficult on account of the 
great numbers of saprophytic bacteria, which tend to over-grow the 
pathogenic bacteria on any of our culture media. 

Tuberculosis is the only exception, and this is due to the fact that 
instead of media we use the animal to separate the tubercle bacilli 
from other bacteria. So far as diphtheria and typhoid bacilli, these 
are almost never obtained from milk; there are only a half-dozen 
instances in which this has been actually done. We should never 
depend, therefore, upon the bacteriological examinations for pointing 



384 BACTERIAL AND OTHER CONTAMINATIONS OF MILK 

out where the danger of infection exists. We must depend upon the 
circumstantial evidence of persons acquiring the disease who consume 
the milk, and then in tracing up the original sources to the infected 
supply. The ordinary bacteriological examinations of milk are for 
the purpose of detecting the condition under which the milk was 
supplied. We know from long experience that the cleaner the milk is 
the fewer the bacteria that fall into it. We know that the cooler the 
milk is kept, the slower will be the development of the bacteria originally 
entering it. 
The following table sets forth these facts very effectively: 



Temperature. 
21° F. (0° C.) 
39° F. (4°C.) 
42° F. (5.5° C.) 
46° F. (6° C.) 
50° F. (10° C.) 
55° F. (13° C.) 
60° F. (16° C.) 
68° F. (20° C.) ' 
86° F. (30° C.) 
94° F. (35° C.) 



Time which elapsed before making test. 



24 hours. 


48 hours. 


96 hours. 


168 hours. 


2,400 


2,100 


1,850 


1,400 


30,000 


27,000 


24,000 


19,000 


2,500 


36,600 


218,000 


4,200,000 


38,000 


56,000 


4,300,000 


33,000,000 


2,600 


3,600 


500,000 




43,000 


210,000 


5,760,000 




3,100 


12,000 


1,480,000 




42,000 


360,000 


12,200,000 




11,600 


540,000 






89,000 


1,940,000 






18,800 


3,400,000 






187,000 


38,000,000 






180,000 


28,000,000 






900,000 


168,000,000 






450,000 


5,000,000,000 






4,000,000 


5,000,000,000 






1,400,000,000 








4,000,000,000 








5,000,000,000 








5,000,000,000 









The bacterial counts, therefore, indicate whether the milk was 
obtained in a cleanly way, and also whether it was kept cool, and to 
some extent as to whether it was quickly consumed. The bacterial 
count also shows the effectiveness of heating the milk. To a very 
slight extent the examination for certain types of bacteria such as the 
streptococcus has some importance as tending to detect a mastitis in 
the cows or other cattle infections, but in the usual city milk, which is 
a mixture of many supplies, very little can be determined from such 
examinations. 



CHAPTER XIII. 

BACTERIAL INFECTIONS AND PARASITIC DISEASES FROM 
MILK, MEAT AND OTHER FOODS. 

By WILLIAM H. PARK, M.D. 

PATHOGENIC BACTERIA IN MILK. 

Tuberculosis, typhoid fever, scarlet fever, diphtheria and septic sore- 
throat are the chief diseases transmitted by means of milk in this 
locality. Poisoning from the toxin of Bacillus botulinus has occurred 
from cheese. In other countries cholera, Malta fever and possibly other 
disease> may be due at times to milk infection. The obscure disease 
trembles is also believed to be due to milk. 

The tubercle bacilli in milk are in the majority of ca^e> derived from the 
cow, but may come from human sources, the typhoid bacilli are entirely 
from man, the contagion of true scarlet fever conveyed in milk is 
probably always from man. but the contagion of a disease closely allied 
to it is certainly given off by cows, suffering from certain septic diseases 
as yet not fully identified. Diphtheria bacilli are probably always of 
human origin, as animals, except cats, practically never suffer from the 
disease and these only under exceptional conditions. The streptococci 
exciting septic tonsillitis are probably usually from cases of inflamma- 
tion of the udder which in turn received their infection from man. As 
milk is usually kept below 60° F. the typhoid bacilli and the streptococci 
are the only germs that we believe increase in any appreciable extent. 

The following epidemics and cases have been recorded in the bulletin 
of the Public Health Service, as produced by cow's milk: 

Epidemics. Cases. 

Typhoid fever 179 6900 

Scarlet fever 51 2400 

Sore-throat 7 1100 

Diphtheria 23 960 

Tuberculosis -4 per cent, of cases in 

children. 

'While this is a very incomplete list, the figures probably give an 
accurate comparative statement as to the relative frequency of the 
different infections. The general introduction of pasteurization has 
almost eliminated milk infection in cities. s 

The cases of trembles (milk sickness), believed to be due to milk, 
have not been collected with sufficient care to be reported. Xo case 
of measles, small-pox, whooping-cough, or mumps has been clearly 
traced to milk. 



386 



PARASITIC DISEASES FROM MILK AND MEAT 



The Relation of Bovine to Human Infection. — The opinions of those 
best able to decide this question have been subject to remarkable 
changes during the past twenty years. At first, in spite of the results 
of early investigations which indicated a difference in virulence, almost 
all considered that the bacilli from cattle were practically identical 
with those from man and could equally well produce human infection. 
All agreed that tuberculosis in cattle should be stamped out, so as to 
avoid human infection. Avian tuberculosis was then sharply dif- 
ferentiated from human, and a little later bacilli from bovine and 
human sources were shown by Theobald Smith to have certain bio- 
logical differences as well as the earlier known differences in rabbit 
virulence. This made it necessary to test a large number of cultures 
from both man and cattle to determine to what degree the bovine type 
was transmitted to man and the human type to the cow, and if such 
transmission occurred how permanent were the differences in the types 
of bacilli. In 1901 Koch startled the medical profession with his 
opinion in the announcement that bovine infection of man was so rare 
that it was a negligible quantity in the fight against human tuberculosis. 

COMBINED TABULATION CASES REPORTED AND OWN SERIES OF CASES. 



. 



Diagnosis. 



Pulmonary tuberculosis 

Tuberculous adenitis, axillary or inguinal . 
Tuberculous adenitis, cervical .... 

Abdominal tuberculosis 

Generalized tuberculosis, alimentary origin 

Generalized tuberculosis 

Generalized tuberculosis including meninges, 

alimentary origin 

Generalized tuberculosis including meninges 

Tuberculous meningitis 

Tuberculosis of bones and joints 

Genito-urinary tuberculosis 

Tuberculosis of skin 

Miscellaneous cases: 

Tuberculosis of tonsils 

Tuberculosis of mouth and cervical nodes 
Tuberculous sinus or abscess .... 
Sepsis, latent bacilli 



Adults 16 
years and over. 



Children 5 to 
16 years. 



Children under 
5 years. 



Totals 



644 


(1?) 


11 


— 


23 


2 


— 


4 


— 


2 


27 


1 


36 


21 


15 


14 


4 


8 


7 


9 


6 


1 


2 


3 


13 


29 


- 


4 


1 


43 


_ 


_ 


1 


_ 


3 


5 


— 


7 


_ 


52 


1 


— 


3 




27 


27 


1 


38 


3 


26 


17 


1 


2 


— 


— 


3 


1 


1 


1 


1 


2 
777 


10 


7u 


36 


1 
215 



65 



Mixed or double infections, four cases. 



Total cases, 1,224. 



This aroused great opposition and investigations were begun in 
England and Germany on a large scale. Ravenel isolated the first 
bovine bacillus in a child in America. Smith in a quiet way continued 
his careful investigation of a number of cases. A group of us in New 
York City have been studying the question at the Research Laboratory. 
As the work of the English and German Commissions and of Smith 
was devoted to selected cases and had succeeded in establishing the 



PATHOGENIC BACTERIA IN MILK 387 

presence of bovine infection in some of these, we decided to take every 
case occurring in several hospitals devoted to children and also several 
hundred cases of adult pulmonary tuberculosis, so as to be able to get 
an opinion as to the relative frequency of infection with each type of 
bacilli. Something over 1 per cent, of the total deaths from tubercu- 
losis are due to bovine bacilli. In little children probably 10 per cent, 
of the total deaths are due to the bovine type. The percentage of 
tubercular glands in young children due to bovine bacilli is fully 30 
per cent. In England the amount of infection due to the bovine type 
seems to be somewhat greater, while in Germany it may be a little less. 
We have found the sparse growth of early cultures of the bovine type 
as contrasted with the vigorous growth of the human type on glycerin 
egg to be the best cultural test for differentiating the two types. If we 
add the 450 cases studied by us to those of all other workers, we get 
the results in the table on the preceding page. 

Taking the cases given in the total tabulation and combining the 
important diagnoses under one heading gives us the following table, 
which shows clearly the percentage incidence of bovine infection. 

PERCENTAGE INCIDENCE OF BOVINE 

Adults 16 years 
Diagnosis. and over, 

per cent. 

Pulmonary tuberculosis 0(?) 2 

Tuberculous adenitis, cervical . . . . 3.6 

Abdominal tuberculosis 22.0 

Generalized tuberculosis 2.7 

Tubercular meningitis (with or without 

generalized lesions) 0.0 

Tuberculosis of bones and joints . . . 3.5 

Caution is necessary in applying these figures, they tell nothing but the 
incidence; the seriousness of the infeciton is indicated in the revised 
table. 

Under certain diagnoses a great many latent or slight infections are 
included, which may never have had any effect on the health of the 
child had not some intercurrent infection led to death. Furthermore, 
due to selection of material, the number of cases of generalized tuber- 
culosis of alimentary origin is markedly out of proportion and bears 
no relation to the incidence of these cases in proportion to other types 
of disease. If we rearrange the figures under these headings leaving 
out all but severe types of disease and consider the selected cases of 
alimentary tuberculosis separately, the following table gives the results. 

1 Exclusive of cases of double infections. In considering pulmonary cases it must, 
however, be remembered that bovine tubercle bacilli have been isolated from the lung 
in cases of generalized tuberculosis in children. 

The number of cases under some of the headings is too small to deduce percentages. 
Reference to the preceding table makes this evident. 

2 If the two bovine cases of the Royal Commission were included, the percentage 
would be 0.3. We have not included these two cases as the additional human cases 
could not be included. If we combine the pulmonary cases regardless of age we can 
then add these cases, giving us a total of 710, exclusive of the one doubtful case, 
Of these, 3 or 0.42 per cent, were bovine infections. 



INFECTION. 1 




Children 5 to 


Children 


16 years, 


under 5 years, 


per cent. 


per cent. 


0.0 


4.1 


36.0 


58.0 


46.0 


59.0 


40.0 


23.0 


0.0 


13.6 


7.3 


0.0 



388 PARASITIC DISEASES FROM MILK AND MEAT 

Only cases under sixteen years are considered, as we have only noted 
the severity of disease in these cases in the tables. The percentage of 
our cases are given for comparison. 

PERCENTAGE OF BOVINE INFECTION. {Revised.) 

Children 5 to lt> years. Children under 5 years. 

Diagnosis. Combined Own Combined Own 

figures. figures. figures. figures, 

percent. percent. percent. percent. 

Abdominal tuberculosis .... 66 50 69 75 

Generalized tuberculosis, aliment ary 

origin 60 - 48 66 

Generalized tuberculosis .... 20 — 11 18 

Tubercular meningitis, secondary to 

tuberculosis of alimentary type — — 72 — 

Tubercular meningitis (other than 

preceding) — — 6 oh 

Revising the percentages in this way gives close agreement. The 
percentages are highest in the relatively less common types of tuber- 
culosis. In the two types of tuberculosis, which mainly constitute the 
fatalities in young children, the percentages range from 5| per cent, to 
18 per cent. All things considered, we feel safe in saying that the 
percentage of deaths from bovine tuberculosis in young children, viz., 
(3 J per cent, to 10 per cent, as deduced from our unselected cases in 
New York City, are applicable to most cities throughout the world 
whose milk supply is similar to ours and is not pasteurized. 

A test carried out during the past three years shows a marked 
decrease in the amount of bovine infection of children. The only cases 
found had consumed raw milk. 

Conclusions. — Bovine tuberculosis is practically a negligible factor 
in adults. It very rarely causes pulmonary tuberculosis or phthisis, 
which causes the vast majority of deaths from tuberculosis in man and 
is the type of disease responsible for the spread of the virus from man 
to man. 

In children, however, the bovine type of tubercle bacillus in those 
consuming raw cows' milk causes a marked percentage of the cases 
of cervical adenitis leading to operation, temporary disablement, 
discomfort, and disfigurement. It causes a large percentage of 
the rarer types of alimentary tuberculosis requiring operative inter- 
ference or causing the death of the child directly or as a contributing 
cause in other diseases. 

In young children it becomes a menace to life and causes from 6| 
to 10 per cent, of the total fatalities from this disease. 

The Relation of the Typhoid Carrier to Milk Infection.— Many 
epidemics of typhoid fever have until recently puzzled investigators 
because, though evidently milk borne, yet no case of typhoid fever could 
be found. The discovery that about 2 per cent, of those who have 
recovered from typhoid fever remain infected and continue during the 
rest of their lives to pa>s typhoid bacilli, has cleared up the mystery. 
Epidemics due to these carriers have already been traced both in New 






PATHOGENIC BACTERIA IN MILK 389 

York ( 'ity and elsewhere. Many observers have already discussed the 
relation of typhoid cases to milk infection. Hands, water, flies, etc., 
may all aid in the transfer of the bacilli from the dejecta to the milk. 
Some years ago we traced over four hundred cases to infection of a 
milk supply by a typhoid carrier who had the disease forty-seven 
years ago. 

The Conveyance of Scarlet Fever by Means of Milk. — As we do not 
know the organism which excites scarlet fever, we are not as clear as 
to the means by which it is spread as we are in the case of tuberculosis, 
typhoid fever and diphtheria. We know, however, that the throat 
secretions are dangerous. Where the infection has been traced it has 
usually been found that the milker has suffered from an unrecognized 
case or is convalescent. It seems as if the contagion must either 
increase in milk or be capable of infecting when greatly diluted, for 
cases have developed from milk after great dilution. 

Septic Sore-throat With or Without a Scarlatiniform Rash. — A 
number of epidemics have come from the milk of diseased cows. 
The etiology of the epidemic is discussed under the disease septic 
sore-throat. The history of a typical outbreak was as follows: 
The milk from a septic cow was delivered to two schools. About 
thirty of the boys who drank the milk developed the disease while 
none of the day scholars who went home to lunch did. Some of 
the cases developed at first only sore-throats, others only the rash. 
On the second day the cases resembled very closely scarlet fever. 
There was no scarlet fever in the town. The milk contained numbers 
of streptococci. In several outbreaks we have been able to obtain 
the same type of streptococcus in the throat of the milker, the 
udder of the cow and in the throats of the consumers who developed 
infection. 

Diphtheria is occasionally produced by milk. The diphtheria 
bacilli usually originate from a mild case, the nature of which was 
overlooked or from a healthy carrier. 

The Detection of Milk Epidemics. — Upon the quick discovery of the 
presence of infected milk will depend the limiting of the number of 
cases. It is important not only that all cases of typhoid fever, scarlet 
fever and diphtheria occurring on the farm be reported, but also that 
all cases in a city be investigated as to the milk supply. 

1. The number of cases of the disease existing and of houses invaded 
in the involved territory, during the time covered by the epidemic. 

2. The number of invaded houses supplied in whole or in part, 
directly or indirectly, by the suspected milk. 

3. The total number of houses supplied with the suspected milk. 

4. The relative proportion of houses so supplied to those supplied 
by other dairies. 

5. The location of the case or cases from which the milk appeared to 
become contaminated and the means by which the infection reached 
the milk. 

6. The time relation of the original case to the epidemic. 



390 



PARASITIC DISEASES FROM MILK AND MEAT 



7. The special incidence of the disease among milk drinkers. 

8. The elimination of other common carriers of infection. 

9. The effect upon the epidemic of taking such measures as will 
eliminate the possibility of milk contamination. 

TRANSMISSION OF PATHOGENIC BACTERIA TO MAN, 
THROUGH MEAT, FISH AND SHELL-FISH. 

Human parasitic bacteria are not commonly found in meat, and 
still more rarely in fish. If present they are usually destroyed in 
the process of cooking. If any survive in complete cooking they 
must pass the ordeal of being subjected to the action of the gastric 
juice. The great majority of dead bacteria and of bacterial prod- 
ucts are harmless when swallowed. Diphtheria and tetanus toxins 
and snake venoms are all harmless. The meat of diseased animals 
after cooking has been eaten numberless times without apparent 
injury, unless preformed heat-resistant toxins were present or infec- 
tion of the meat occurred after cooking. It is, however, the general 
practice that the meat of animals which are sufficiently infected to 
be truly sick should not be eaten, and when the bacteria are of a 
kind like anthrax, which are capable of causing intestinal infection, 
that the meat should be destroyed. Under many conditions, when 
certain tissues only are involved and the others are sound, it is proper 
to consume the latter, as in tuberculosis. The general rule in this 
infection is to use the meat from cattle that have localized disease 
only. The same is true of the meat from hogs. Every part that 
contains tubercles should be removed. When an animal has general 
tuberculosis the whole carcass is destroyed. The bovine bacilli are 
dangerous only to infants and children. (See Milk Infection.) 

Typhoid fever has rarely been traced to oysters, clams and mus- 
sels. The outbreak described by Professor Conn had twenty-three 
victims. We have traced several such outbreaks in the neighborhood 
of New York City. Paratyphoid, dysentery and ordinary diarrheas 
may also be caused by shell-fish. Some have apparently shown 
that oysters retain their infectivity for several weeks when placed in 
unpolluted water. In our tests the oysters when healthy free them- 
selves of infection in a few days. Foote showed that oysters kept in 
storage might hold viable typhoid bacilli for a month. 



POISONING BY MEAT AND FISH. 

The infection may be a result of disease of the animal or it may be a 
postmortem contamination. The cases reported have almost always 
been in those persons who have eaten raw or imperfectly cooked meat. 
Animals suffering from septicemias and fatal diarrheas are liable to 
be infected with the paratyphoid or related bacilli. 

In 1888 Gartner isolated a bacillus from the suspected meat and 
obtained the same organism from a person that died in an outbreak. 
He named this the "Bacillus enteritidis." 



POISONING BY MEAT AND FISH 



M\ 



Poisoning by Meat and Fish. — The use of partially decayed meat and 
fish was more frequently the cause of illness in the past than today. 
This type of food-poisoning usually exhibits the symptoms of an 
acute gastro-enteritis, the more severe cases showing systemic symp- 
toms of poisoning. A fatal outcome is infrequent. The cases are more 
common in warm weather. Such poisonings have been attributed 
to the so-called "ptomains," substances derived from the protein 
of the meat due to the proteolytic activity of putrefactive bacteria. 
The food commonly shows evidences of spoilage, although in some 
instances it may be slight. It is claimed that the ingestion of foods 
contaminated with B . proteus will give rise to gastro-enteritis, although 
no spoilage is evident to the senses. 

In most instances food-poisoning is due to the presence not of 
proteolytic products but of certain types of bacteria or their toxins, 
viz., bacilli of the paratyphoid enter itidis group or B. botulinus. 

It is now know that the paratyphoid-enteritidis types B. enteritidis 
and B. cholera? suis, are encountered in the domestic food-producing 
animals. Both bacilli are met with in hogs, usually as secondary 
invaders in hog cholera. B. enteritidis is the usual type in cattle. 
If meat from infected animals is used for food, poisoning commonly 
results. Sound meat may be contaminated by contact with the 
meat of diseased animals. The likelihood of poisoning as well as 
the severity of the disease will depend on how and how long such 
meat is kept. If the bacilli have an opportunity to multiply freely 
and produce large amounts of toxin the meat will cause disease even 
though the bacilli be killed during cooking — that is, the toxin is heat 
resistant. In this connection it is well to remember that even though 
there be no preformed toxin, cooking could not be relied upon as a 
means of rendering infected meat safe for consumption, unless it be 
thorough, as bacilli might survive in the center of the meat. The 
type of disease depends on the relative proportion of preformed 
toxin. If much is present the disease is more acute. If viable bacilli 
are present they may not only cause an enteric infection but invade 
the blood stream, giving rise to a febrile disease of short duration. 
This type of food-poisoning has been most commonly reported from 
European countries. The following is a characteristic example: 

An apparently healthy calf was slaughtered. Two days later a baker 
made 160 meat pies. Over 50 persons were made sick, and 4 of these 
died. These 4 ate pies which had been kept ten days or more. The 
outbreak was due to the Bacillus enteritidis, which was believed to 
have greatly multiplied during the two days' storage at a moderately 
warm temperature. All the cases presented similar symptoms. The 
chief of these were vomiting, diarrheas and shivering. In some cases 
collapse occurred. Pains in the abdomen and back were felt by many. 
The symptoms began in from five to fourteen hours after eating. Some 
cases of poisoning from fish are apparently due to protein susceptibility 
of those eating it. 

Botulinus-poisoning has been associated not only with meat but 
also canned vegetables. It is discussed below. 



302 PARASITIC DISEASES FROM MILK AND MEAT 

Some cases of poisoning from fish are apparently due to protein 
susceptibility of those eating it, the fish itself being of excellent 
quality. 

Botulism is due to the contamination of foods by the B. botulinus. 
This bacillus is not an infectious organism but produces a highly 
poisonous extracellular toxin in the food, which toxin differs from 
other similar toxins in that it is poisonous when taken by mouth. 
Botulism abroad has been most frequently due to contaminated ham, 
sausages and canned fish. In this country nearly all the cases have 
resulted from the use of canned vegetables and fruits, especially 
beans, asparagus and ripe olives. The disease is more common in 
the West. Home-canned vegetables have been most frequently 
involved. The bacillus is a spore-bearing anaerobe. If heating is 
insufficient the spores survive, germinate and then multiply in the 
absence of oxygen and produce the toxin. This takes time, and 
poisoning usually follows the consumption of foods which have been 
prepared for some time. 

The foods thus contaminated show evidences of spoilage. The 
most characteristic change is the appearance of a rancid butter odor, 
although this may be overlooked. In the case of vegetables or olives 
the presence of a cloudy liquor should be considered highly suspicious. 

The symptoms of poisoning generally appear in twenty-four to 
thirty-six hours after ingestion of the food. They consist of secre- 
tory disturbances and motor paralysis. The former is evidenced 
by suppression of the salivary secretion or the presence of an excessive 
mucous secretion. The latter is shown by eye symptoms, such as 
disturbances of accommodation and ptosis; difficulty in swallowing; 
aphonia; difficulty in breathing and obstinate constipation. Con- 
sciousness is unimpaired and death results from asphyxia due to 
respiratory paralysis. The disease is highly fatal and very little of 
the contaminated food is necessary -to cause a fatal outcome. 

Protection from this type of food-poisoning is relatively simple 
with canned goods. The toxin is quickly destroyed at the boiling- 
point of water, so that heating can be relied on as an absolute safe- 
guard. If absolute safety is desired canned goods should be boiled 
before use, even if it is to be used subsequently for cold dishes. 

No food should be used, however, which shows any evidence of 
spoilage, and canned goods, sausages, etc., which are suspicious 
should never be tasted to determine whether they are spoiled. 

Adequate heating of canned goods and the use of 10 per cent, 
brine in pickling will prevent the subsequent development of the 
bacillus. An antitoxin can be prepared which will neutralize the 
toxin. This probably has therapeutic value if given soon after 
swallowing the poison. There are two types of bacillus, differing 
one from the other in the toxin produced. It is necessary therefore 
to have a bivalent antitoxin available if it is to be used in all cases. 
There is no data available as to the value of antitoxin in the treatment 
of the disease in man. Limber-neck in chickens and certain types of 



POISONING FROM PLANT FOODS 393 

forage-poisoning are forms of botulism. The cases of poisoning of 
any kind from canned goods are remarkably few. 

EGGS. 

Of all foods eggs are less liable to convey disease or contain harmful 
properties than any other single product or animal food. No infection 
of the hen or other bird, so far as known, is transmissible to man 
through its egg. Some persons, however, have an "idiosyncrasy" 
toward eggs resembling anaphylaxis, and eating of only a small quantity 
of egg-protein is liable to bring on an attack. 

In the trade, eggs, 'besides being sold as fresh and refrigerated, are 
classified as "rots, ' "spots," "checks," "ringers," "checkers," "dirty 
shells," "heated," or "incubated," etc. They are assorted by inspec- 
tion and candling. The eggs are held before a bright light or candle, 
when the movable yolk may be clearly seen, if the eggs are translucent, 
as well as the air space at the larger end. An expert candler soon 
detects the quality of the egg. Rotten eggs are known as "red rots" 
and "black rots," according to the putrefaction present. The opaque 
portions seen under the light are termed "spots," which may be due 
to molds that have got into the eggs through a crack in the shell, or to 
embryos or foreign bodies. "Checked" eggs are cracked eggs. "Rin- 
gers" contain small embryos of a ring or disk-like shape, while "check- 
ers," as the name indicates contain larger embryos. "Heated" eggs 
are those which have been exposed to the heat of summer for several 
days and have become shrunken through loss of water by evaporation. 
Hence heated eggs are also known as incubated eggs. Spring and fall 
layings are more desirable than those collected during the summer 
months, for the above reasons, also because they contain fewer bacteria 
and thus keep better than eggs laid in the summer time. 

Large quantities of eggs are now opened and mixed, then frozen or 
dried, and these products are much used by bakers and others. 

POISONING FROM PLANT FOODS. 

Many plants contain physiological poisons, such as aconite, strych- 
nin, ricin, abrm, muscarin, and other substances which are normally 
present. Some plants contain certain parasites, such as rye and other 
grains, which produce ergotism. Poisons may also develop in putrefy- 
ing vegetables as the result of bacterial action, which are perfectly 
wholesome when fresh. Certain vegetables, such as lettuce, celery, 
watercress, radishes, etc., which are eaten raw, may convey typhoid 
fever cholera, dysentery, both amebic and bacillary, the eggs and 
larvae of animal parasites, and other infections. All vegetables there- 
fore, which are to be eaten raw should be carefully washed beforehand, 
in order to cleanse them of impurities such as manure or other excre- 
ment, with which they may have become contaminated in the field or 
garden. 



394 PARASITIC DISEASE FROM MILK AND MEAT 

Reference has already been made to an unbalanced diet consisting 
largely of polished rice as the cause of beri-beri, and to a one-sided 
or faulty diet as the cause of pellagra. Urticaria and other anaphy- 
lactiform symptoms may be produced in susceptible persons by the eating 
of strawberries, blackberries, tomatoes and cereals. 

Ergotism is a form of food poisoning produced by the prolonged 
use of meal made from grain containing the fungus claviceps purpurea, 
which develops in the flowers of rye and other grains. This affection 
is practically unknown in America, and is now becoming rare even in 
Europe, where it was not infrequently met with. 

Mushroom-poisoning is due to eating a species of poisonous mush- 
rooms through mistake for the edible varieties. Amanita is the most 
poisonous of the mushroom families. The symptoms come on sud- 
denly after an incubation of six to fifteen hours with pain in the 
abdomen accompanied by great thirst, vomiting and profuse watery 
diarrhea, the victim finally sinking into a deep coma after four to 
eight days. 

Potato-poisoning is due to poisonous principle solanin which is found 
in small quantities in those tubers of the potato, that have lain, during 
growth, partially exposed above ground, and in those which, during 
storage, have become well sprouted. Potatoes have long been known 
to contain minute quantities of this poison, but it is only under certain 
circumstances, as above noted, that the amount of the poison is sufficient 
to produce serious disturbance of the system. 

PARASITIC ORGANISMS. 

The Trichina spiralis, echinococcus and cysticercus, which frequently 
infest the meat of animals especially hogs, are capable of giving serious 
infection to man when meat infected by them and insufficiently cooked 
or raw is consumed. 

The trichina is the most important of these. It frequently occurs 
in the flesh of hogs, rats, dogs, cats and other carnivorous animals. 
The common host of Trichinella spiralis is the rat, which gets infected 
about slaughter-houses and butcher shops. Hogs become infected 
by eating rats, through feces or directly from infected offal. Man 
secures the infection by eating trichinous pork. 

The trichinae are found in two forms : The mature worms inhabit 
the intestinal canal; the immature form is found in the striped muscle. 
This parasite was first described by Paget in 1833. Trichina? are small, 
thread-like worms which, when found in the muscle or fat of pigs, are 
coiled in tiny cysts. To the naked eye they look like small white 
specks. Sections of muscle treated with weak caustic potash solution 
for a few minutes are rendered sufficiently transparent to reveal the 
coiled worm under a low-power lens. The muscle may be pressed 
out thin enough for examination by using an apparatus made of 
two pieces of plate glass. These plates are forced together by means 
of screw and bolt at each end. 



PARASITIC ORGANISMS 



395 



The trichinae gain access to their host in the following manner: 
Flesh containing trichinae is taken into the stomach and digested. The 
enclosed worms are set free and mature in the intestinal canal. Here 
sexual reproduction occurs and each female worm produces hundreds 




Fro. 56. — Trichinae in human muscle, showing thickened capsule. X 75. (Harrington.) 




Fig. 57. — Trichinae in human muscle. X 75. (Harrington.) 



396 PARASITIC DISEASE FROM MILK AND MEAT 

of young. These young forms begin at once to migrate through the 
intestinal walls and other tissues until they become imbedded in the 
striped muscle. 

Localized epidemics of trichinosis have been reported from time to 
time in this country and in Europe. Meat known to be infected should 
not be consumed, but when necessary it can be rendered harmless 
through cooking. A temperature of 70° C. destroys the life of the 
parasite within a few r minutes. The frequent occurrence of trichina? 
in pork emphasizes the fact that meat should never be eaten without 
thorough cooking. Salted and smoked pork are not free from danger. 
Uncooked ham and sausage are almost as dangerous as fresh pork. 

The tape-worm is next in importance of the parasites transferred 
from meat to man. This in its larval forms exists in beef and pork 
respectively as Cysticercus bovis and Cysticercus cellulosse. Such 
meats are known as measly. The animals are the intermediate host 
and man the final host. The Cysticercus bovis dies within three weeks 
after the slaughter of its host. Measly beef kept for three weeks in 
cold storage is therefore considered to be safe. It is killed in twenty- 
four horns by pickling solutions of common salt. It is not killed by 
ordinary smoking or salting. The Cysticercus cellulosse is somewhat 
more hardy. Both forms are killed by a temperature of 60° C. for five 
minutes. The Bothriocephalus latus infects, in some localities, the 
sturgeon, pike, perch and salmon. It is rarely met with in this country. 
It is killed surely if the fish is properly cooked. 



CHAPTER XIV. 

THE SOIL. 

By ARTHUR R. GUERARD, M.D. 

Soil is a term applied to the superficial unconsolidated portion 
of the earth's crust, composed of broken and disintegrated (weathered) 
rock mixed with varying proportions of decaying organic matter 
(humus). The processes by which soils are formed from the parent 
rocks are mechanical and chemical, and sometimes biological. The 
fertility of a soil is in part determined by the character of the parent 
rock. Thus granite, richer in the elements of plant food, yields a more 
fertile soil than the silicious sandstones. 

According to the method of their formation soils are classed as 
sedentary or transported. When a soil is found resting on its parent 
rock it is spoken of as sedentary soil. Such formation may show 
gradual transition from the fully formed soil at the surface to the 
solid rock beneath. With this class may be grouped the humus or 
peaty soils due to accumulations of organic matter in bogs, swamps 
and marshes. In many cases the residual products have been removed 
from the places of their formation by the action of water, ice (glaciers) 
and wind, and deposited elsewhere as clayey, sandy, or loamy soils, 
often representing the mingling of material from several sources. This 
type is termed transported soil, and, though naturally variable in 
character, includes some very productive soil. The most important 
soils of this class are the alluvial soils, such as occur in river and flood- 
plains and deltas, as in the case of the Nile and the Mississippi Rivers. 
In the northern half of the United States much of the soil is of the glacial 
drift type and represents the debris of rocks of various kinds brought 
down from the north during the glacial period. 

Eolian soils are those formed by wind action. They include: (1) 
sand dunes, shifting, sandy soils heaped up by wind action upon ocean 
coasts and shores of inland seas and lakes; (2) ash soils, the accumula- 
tion of ashes ejected by volcanoes. The deposits are often of consider- 
able extent and are frequently very fertile. Such soils are found in 
Nebraska, Colorado and Montana, and other volcanic regions. 

Soils containing an excess of soluble salts are found scattered through- 
out regions of different or irregular rainfall and are known as alkali 
soils. Humus, peaty or moor soils are composed largely of organic 
matter. The purest types are represented by accumulations of peat 
formed in ponds and swamps; massive marshes and muck soils repre- 
sent a less pure variety. When properly drained and aerated and 
freed from excess of soluble salts, they often prove very productive. 



398 



THE SOIL 



In practice soils are classified as gravelly, sandy, loamy, clayey, 
calcareous, humus, peaty, etc., distinctions based on the fineness of 
the soil particles and the relative proportions of sand, clay, lime and 
humus which they contain. Soils are also frequently classed as light 
and heavy, according to the ease or difficulty of tillage. The produc- 
tiveness of a soil depends chiefly upon its chemical composition and its 
physical or mechanical properties. Chemical and physical or mechani- 
cal analysis separates soil constituents into two general classes: (1) 
plant food constituents and (2) physical constituents. The food con- 
stituents considered necessary to plant growth are nitrogen, sulphur, 
phosphorus, calcium, magnesium, potassium, iron and probably 
manganese, in various forms of chemical combination. The physical 
constituents, constituting the larger proportion (90 to 95 per cent.) 
of the entire soil mass, act as a mechanical support to plants and 
furnish a medium for root growth, but have little more than an indirect 
value as fertilizing agents. As a rule they consist very largely of silica. 
Chemical Properties. — The average composition of -soil of humid 
and arid regions in the United States is shown in the following table 
(Hilgard): 





Humid 


region. 


Semi-arid region. 


Arid 


region. 


Constituents. 




Per cent. 




Per cent. 


Per cent. 


Insoluble matter 
Soluble silica . 


84 
4 


171 
04/ 


88.21 


75 
8 


JJ} 83.50 


69. 16 \ 

6.71/ 


75.87 


Potash. .... 






0.21 




0.33 




0.67 


Soda 






0.14 




0.32 




0.35 


Lime 






0.13 




0.70 




1.43 


Magnesia .... 






0.29 




0.47 




1.27 


Iron oxide 






3.88 




2.08 




5.48 


Alumina .... 






3.66 




4.57 




7.21 


Magnese oxide 






0.13 








0.11 


Phosphoric acid . 






0.12 




0.21 




0.16 


Sulphuric acid 






0.05 




0.02 




0.06 


Humus .... 






1.22 




3.24 




1.13 


Nitrogen in humus . 






* 




6.67 




12.50 


Nitrogen in soil . 










0.22 




0.13 


Less than 5 per cent. 




















Actual fertilizing constituents, viz., potash, phosphoric acid, nitrogen, 
lime, etc., are relatively small, arid soils showing larger proportions 
than humid soils. Other mineral constituents are usually present in 
sufficient qualities to supply the needs of plants. Humus is important 
as a soil constituent not only on account of its beneficial effect on the 
physical properties of soils, but as a source of nitrogen, as well as of 
available phosphoric acid, potash, lime, etc. The nitrogen of humus 
is converted into a form (nitrate) available for plants by the process 
of nitrification through the agency of microorganisms. This includes 
three stages, viz.: (1) the transformation of organic nitrogen com- 
pounds into ammonia; (2) the conversion of ammonia into nitrites; 
(3) the formation of nitrates from the nitrites. The first of these 
changes are brought about by a variety of organisms of the putre- 
factive class, the most prominent being Bacillus mycoides and Protevs 



PHYSICAL PROPERTIES 399 

vulgaris, while the second and third are the work of specific organisms, 
nitrosomes, nitrous organisms and nitrobacterin, nitric organisms. The 
retrograde action known as denitrification, by which nitrates are 
reduced to the less highly oxidized forms and even to free nitrogen, 
is the work of microorganisms also of various kinds, some aerobic, 
others anaerobic. Humus may be said to be the final visible product of 
decomposition of organic matter in the soil, in the course of which a 
great variety of organic compounds, some beneficial, some harmful 
(toxic) to plant growth, are produced. 

Physical Properties. — Physical properties of soils of special impor- 
tance are color, weight, fineness of division or texture, structure of 
arrangement of particles, adhesiveness and relation to gases, heat, 
moisture and dissolved solids. Variations in these properties determine 
to a large extent the productiveness of soils. Good tilth and texture 
with accompaniment of good water conditions, aeration and tempera- 
ture are fully as essential to plant growth as an adequate supply of 
plant food and may be in a measure controlled by man. Physical 
properties of soils are so largely dependent upon their natural char- 
acter, and can be modified to such a limited extent by man, that it is 
of great importance to select soils with special reference to the natural 
suitability of their physical character to the crop to be grown. The 
physical properties of soils are determined also by the proportion they 
contain of stones, gravel, sand, clay, lime and organic matter. A 
sandy soil is dry, warm and easy to work, but as a rule naturally poor, 
with little absorptive power. A clayey soil is apt to be cold, wet and 
difficult to till, but to have high absorptive power. Clayey soils gen- 
erally contain more plant food than sandy soils. Humus makes 
soils light in weight and dark in color and greatly increases absorp- 
tive power. Lime not only has value as a plant food, but improves 
the structure of soils and corrects acidity. It also promotes the decom- 
position of organic matter and nitrification and other biological 
activities. Mechanical analysis, which separates the particles of a soil 
into six or more grades of fineness, ranging from stones and gravel 
through sand and silt to clay, furnishes a valuable means of securing 
data for judging of the physical properties of soils. 

The productiveness of the soil depends very largely upon its texture 
and structure, i. e., the size of the particles and their arrangement. 
These determine the circulation of water and gases, solution and 
retention of plant food, and the growth of plant roots. When the grains 
are single or separated the soil is said to have a puddled structure, 
while a compounding of the soil grain gives a flocculated structure. 
The latter is desirable in all good soils, as it increases the pore space 
and facilitates the circulation of air and water through the mass. 
Flocculation may at times be caused by frost action, but more fre- 
quently is produced by the action of lime. Fertilizers vary in their 
action, some like nitrate of soda, producing puddling, others producing 
flocculation. The finer the soil particles the greater the injurious 
effects of puddling, clay soils suffering from this cause more than sandy 



400 THE SOIL 

soils. Puddling increases the water-retaining power, thus retarding 
percolation, but may accelerate capillary rise of water. Flocculation 
decreases the retention of water, aids percolation and may retard 
evaporation. Water passes more easily from a coarse to a finer layer 
than from a fine layer to a coarse one — hence when the farmer firms 
the soil by rolling and then loosens the surface by harrowing, he destroys 
the capillary spaces and so checks the escape of water into the air. 
Water is held near the surface, and is readily accessible to the roots of 
plants. The action of mulch depends upon this principle. In humid 
regions the clay particles of the soil are usually Avashed down to a layer 
several inches below the surface, the surface layer being called the soil 
proper, and the lower one subsoil. In arid regions this difference does 
not exist, but the fine clay particles are evenly distributed throughout 
the soil layers. Soils vary widely in their absorptive power for water 
and for fertilizing matter. Of the three principal fertilizing constit- 
uents — nitrogen, phosphoric acid, and potash — soils apparently have 
the least retentive power for nitrogen (in the form of nitrate) and the 
greatest for phosphoric acid. The relation of soils to water probably 
more than any other one factor determines their productiveness. 
Water is not only necessary as a constituent of plant tissue, but it 
performs a most important function as a solvent and carrier of food in 
both soil and plant. The temperature of soils is modified by a variety 
of conditions, e. g., a dark-colored soil is usually warmer than a light- 
colored one; soils so exposed as to receive a large amount of the direct 
rays of the sun are warmer than those not thus exposed; dry soils are 
warmer than wet. 

Biological Properties. — Living organisms — roots of plants, insects, 
earth worms, etc., but especially bacteria — play an important role in 
soil formation and fertility. Bacteria aid in the disintegration of soil- 
forming rocks and increase the supply of available mineral plant food, 
fix free nitrogen both directly and in symbiosis with leguminous plants — 
viz., the group of bacteria known as B. radicicola — render organic 
nitrogen available to plants by nitrification or cause loss of soil nitrogen 
by denitrification, and in some cases produce substances in the soil 
which may be either harmful or beneficial according to circumstances. 
Recent investigation has indicated the practical possibility of curbing 
the harmful and promoting the beneficial microbiological activities in 
the soil by various methods of treatment, more especially by partial 
sterilization of the soil by means of heat or volatile antiseptics. 

Soil Pollution. — The soil may be polluted in various ways and in 
widely differing amounts, but the nature and amount of pollution are 
of less importance relatively than the point of entrance. Some of these 
pollutions are unavoidable and others avoidable. 

The unavoidable pollutions include the urine and droppings of 
animals, the carcasses of such as have died and have escaped the notice of 
other animals that act as scavengers and vegetable matters of all kinds 
in various stages of decay. These, lying at or near the surface, are of 
comparatively little importance, except under very unusual conditions, 



SOIL BACTERIA 401 

when large numbers of horses, cattle and other animals are killed or 
die, as in time of war or flood or epidemics, since exposed to natural 
processes of purification, they are resolved into simple innocuous sub- 
stances, which are absorbed by plant life or washed downward into the soil. 

The avoidable pollutions are mainly those which man deposits 
beneath the surface, and these are first, and of minor importance, the 
bodies of the dead, and second, of vast importance, the excreta and 
other organic filth that constitute sewage. The temporary storage of 
filth in water-tight receptacles built under ground can, of course, do 
no harm to the surrounding soil. Water-tight cesspools gradually 
become filled and require to be emptied, but those with pervious 
bottoms permits the escape of the contents downward, the filth thus 
introduced is below the zone of bacterial activity of the beneficent 
kind, and becomes stored up in the subsoil or is washed away gradually 
by the ground water, which thereby is made unfit for human consump- 
tion. Organic matters deposited in the upper strata of the soil are 
resolved into their constituent elements with greater or lesser rapidity 
according to local conditions of distance from the surface, temperature, 
degree of moisture and permeability to air, the process advancing 
most rapidly in a well-ventilated, moderately dry soil near the surface, 
and most unfavorably in wet, compact soils, far from the surface. 

In the decomposition of organic substances in the soil, no offensive 
odors are noticed, if a substantial layer of earth is interposed between 
them and the atmosphere. The soil has the faculty of absorbing gases 
and vapors just as it has the power to retain water in its interstices 
and on the surface of its constituent particles, a property which is 
illustrated in the common earth-closet. The soil acts in this respect 
like charcoal. Perhaps the most striking illustration of the affinity of 
soil for odors is the fact that illuminating gas from leaking street 
mains may be robbed of its odorous constituents by the soil to such 
an extent that, being drawn into houses with the soil-air, its presence 
often escapes detection until the production of poisonous effects 
attracts attention to the existence of an unusual condition of the air. 

Soil Bacteria. — The bacteria of the soil are found almost wholly 
in the superficial layers; below a depth of 12 feet they are relatively 
few in number. They are far more numerous in rich garden soil than 
in ordinary sand and clays, due to the fact that they need organic 
matter for their growth and multiplication. In addition to the presence 
of organic matter, moisture and certain limits of temperature are also 
necessary for their development. Dryness and extremes of heat and 
cold are unfavorable for their growth. Saturation with water may or 
may not be unfavorable, according to the variety. In rich soil the 
number of bacteria ranges from hundred thousands to millions per 
cubic centimeter in the surface layers, below which they decrease in 
number very rapidly, until at ten to twelve feet below the surface, 
the soil is practically sterile, except for those that have been washed 
down or carried bv burrowing animals, or deposited bv man in organic 
filth. 

26 



402 



THE SOIL 



The soil bacteria are mainly of the beneficent varieties, the sapro- 
phytes which perform useful offices, including the numerous kinds of 
the nitrifying organisms. While different species of pathogenic bac- 
teria have been found in the soil, and though certain of them, such 
as the bacilli of tetanus and malignant edema are often present, this class 
of organisms finds, as a rule, the conditions in the soil unfavorable to 
development. 

The relation of the soil to the various pathogenic bacteria will be 
discussed further under separate headings. 



CHAPTER XV. 

WATER SUPPLIES AND THEIR PURIFICATION. 

By JAMES T. B. BOWLES, B.S. 

Introduction. — In discussing the subjects of water supply and 
sewage disposal, the writer wishes to state that it has been his inten- 
tion to introduce the latest and most approved theories that have 
developed on this subject. 

To carry out this plan, he has used, not only the results obtained 
from his own investigations, during his wide experience in this and 
other countries, but has tried to bring out the accepted ideas of others 
who are working along this line. 

The definitions of terms given are those which are generally accepted 
by all workers, as well as the standard methods for the examination of 
water and sewage. 

In studying water supplies we find that the earliest method of 
artificially obtaining water was by merely digging wells, which at first 
were very crude in form, being only shallow holes in the ground. 
However, history tells us that the Chinese have been familiar with the 
sinking of deep wells through rock strata from an early period. 

It is found that the greatest development of water works construc- 
tion in the early times no doubt took place during the very prosperous 
period of the Roman Empire. Great aqueducts were constructed 
many miles in length. First of these was built about 312 B.C. and the 
last about 305 a.d. Besides the Roman aqueducts that were con- 
structed at this time, water supplies were developed for other cities, 
such as Paris and Lyons in France, Metz in Germany and Seville in 
Spain. 

Modern water works began to be developed in Paris and London 
at the beginning of the 17 th century, and the development has been 
very rapid in both Europe and America since 1800. 

SOURCES OF WATER SUPPLY. 

The sources of water supply are, as a rule, divided into three classes, 
as follows : 

1. Rain or snow water. 

2. Surface water which would include ponds, lakes, streams and 
rivers. 

3. Ground water, including springs and wells. 

Rain Water. — When collected from a clean impervious surface in 
the open, it is the purest natural water. Rain water is collected in 



404 WATER SUPPLIES AND THEIR PURIFICATION 

barrels and cisterns to be used for drinking purposes, and this method 
is still carried on in some parts of the country. However, this source 
of water supply has never been looked very favorably upon by Sani- 
tarians on account of the careless manner in which the water is stored. 
Furthermore, these cisterns and rain barrels are excellent places for 
breeding mosquitoes, and at one time were the main sources for breed- 
ing of the yellow fever mosquito which caused many epidemics over the 
country. Rain water, being very soft, attacks iron, lead, zinc and other 
metals, and for that reason storage tanks or delivery pipes should not 
be made of these materials. 

The water should be filtered in order to take out the impurities 
found in the air of cities. 

Surface Waters. — The waters included in this class are those from 
rivers, lakes, ponds and impounding reservoirs. Unfortunately 
streams are used as natural sewers of the regions which they drain, 
and for this reason water from this source should not be used without 
some method of purification. 

Lakes and Ponds. — These are excellent sources for water supply 
if of sufficient size and contain no industrial or domestic waste. 
However, owing to the possibility of contamination from their 
water-sheds it would be the safest plan to treat these waters with 
liquid chlorine. 

Impounding Reservoirs. — Impounding reservoirs are nothing more 
than artificial lakes or ponds. In many localities, especially in smaller 
ones, the town supply is obtained by placing a dam across a narrow 
valley through which a small creek flows. While this is often true of 
small towns, large supplies are also obtained in the same manner. 
For instance, it might be said that New York City obtains its supply 
by impounding a number of streams flowing from the Catskill Moun- 
tains. 

Ground Water. — This class covers those obtained from springs, 
shallow and deep artesian wells. 

Springs. — Springs are formed when ground water is caused to over- 
flow upon the surface, as a result of geological formation. They are 
often found to be polluted, which might come from a number of dif- 
ferent sources. A crack or a break in the geological formation would 
allow a direct seepage from a cesspool or a barn-yard to contaminate 
it. In another instance, unless the outlet of the stream is protected 
by a cement casing, surface washings may get into it and pollute the 
water. 

Shallow Wells. — Shallow wells, as a rule, are very dangerous, as quite 
often they are nothing more than a hole in the ground which collects 
surface drainage. (See Fig. 44.) 

A Deep or Bored Well. — A deep or bored well may be of different 
depths, depending upon the strata through which it is bored. It is 
always best to have these wells covered with a concrete casing in order 
to prevent frogs, mice and bugs from crawling around it. Such a 
means of prevention of surface contamination applies to all wells. 



SOURCES OF WATER SUPPLY 



405 



Artesian Wells. Artesian wells generally refer to wells where the 
depth usually exceeds 75 to 100 feet. The waters of these wells are 




Fig. 58. — Contaminated well. Pollution from privy and barn passes through rock 

fissures. 

often high in mineral content as well as containing dissolved gases, 
and for this reason have certain medicinal properties. An artesian 




Ground 
Water 



Fig. 59. — How a well located on high ground may be polluted by the contents of 
a cesspool lower down. (Harrington.) 



water is very often impossible to be used as a general municipal supply 
on account of it causing trouble as an industrial water. 

In classifying waters, certain accepted terms well known to water 



iOli 



MATER SUPPLIES AND THEIR PURIFICATIOX 



experts are used. For instance, we think of a water as good, bad or 
non-potable. 

By the term good water is meant one that has a good sanitary quality 
when determined by physical inspection, bacteriological and chemical 
analysis, and a sanitary survey of the water-sheds. 

By polluted or contaminated water is meant, one containing organic 
wastes of either animal or vegetable origin and this would be referred 
to as a suspicious water. 

By an infected w r ater is meant a w T ater that actually contains the 
specific microbe or organism of human diseases. 

The term potable means whether or not the water is drinkable. 



Ordinary 







Fig. 60. — Geological formation favorable to the obtaining of water by means of artesian 

wells. (Harrington.) 



THE CONSUMPTION OF WATER. 

This depends upon a number of conditions. For sanitary reasons 
a generous use of w T ater is always to be encouraged. For instance, 
the flushing of streets is the best known means for cleaning them. 
The installation of sanitary sew T ers is also most important, as in this 
w T ay cesspools and privy vaults can be done away with. At the same 
time the conservation of pure water and the economic use of purified 
water should always be kept in mind. 

The United States census report for 1915 gives the average per capita 
daily consumption of 201 American cities as 139 gallons with an aver- 
age of 40 per cent, of their systems metered. 

The average per capita consumption of 46 cities of Xew York State 
is 169 gallons per twenty-four hours, with an average of 52 per cent, 
of their systems metered. These statements are made to show the 
importance placed upon meters. Fifty American cities having at least 
95 per cent, of their systems metered, reported a year ago that their 






TRANSMISSION OF WATER-BORXE DISEASES 407 

average daily per capita consumption was 79.4 gallons. Before meters 
were installed the average daily per capita of 25 of these cities was 
153.2 gallons. Thus it can be seen that the only effective and economi- 
cal method of reducing water waste and leakage to a minimum is 
through the general installation of meters. 

DUAL WATER SUPPLIES. 

In some instances a dual supply system has been thought to be 
economical and judicial to install. This consists of the use of an 
untreated river water or lake, which may be more or less contaminated 
but otherwise not objectionable for use in street washing, flushing of 
mains, sanitary connections and industrial works, when not used for 
drinking purposes. Then in combination with this system is another 
one which may be taken from the same source, but treated in such a 
manner as to make it a good, potable water. If not taken from a 
source as the first system described, it may be taken from another, 
such as deep wells, whose purity is assured. 

The objection to a dual system is that there is always a chance for 
the water from a questionable source to be used for drinking purposes, 
or possibly a chance for the good water supply to be contaminated by 
the poor one. Such a system is not to be recommended except under 
extraordinary conditions. 

THE RELATION OF POLLUTED WATER TO THE TRANSMISSION 
OF WATER-BORNE DISEASES. 

Water supplies may be polluted by three classes of material : 
Vegetable and animal refuse, waste from human beings and waste from 
industrial industries. 

If the water is contaminated from the latter source, unmixed with 
either of the other two sources, it cannot cause infectious diseases and 
can only be of danger to human beings using it in proportion to the 
amount of physical or chemical action which these wastes may have on 
the human body. Certain kinds of trade waste contains poisonous 
chemicals and even though diluted may cause trouble. 

A water which contains vegetable or animal refuse but does not 
contain any human excrement will not be the means of transmitting 
any infectious disease to human beings, under ordinary circumstances. 
However, it is as yet more or less uncertain whether a water containing 
a large amount of organic matter of vegetable or animal origin, exclud- 
ing that from human sources, is liable to cause pathological or disease 
conditions. For instance, such a water might be the means of stimulat- 
ing gastro-enteritic and diarrhea in infants, young children or invalids. 

When we consider the pollution of a water with waste from human 
beings, we find this kind of pollution the most important of all. Among 
the common water-borne diseases we have typhoid fever, dysentery, 
and cholera. However, it is possible to use for potable purposes a 



(08 WATER SUPPLIES AND THEIR PURIFICATION 

water polluted with human excrement from perfectly healthy indivi- 
duals who are not producing any disease bacteria, and yet not have any 
resulting disease from using such a water. The chief danger of using 
such a water is the possibility that a ease or eases of water-borne 
diseases may at any time occur among a group of healthy persons, such 
as typhoid carriers, polluting the water. The liability of this polluted 
water to produce disease will depend upon two factors: Chiefly the 
amount of the pollution and the directness in which it reaches the con- 
sumer. If the infectious material is large in amount, but a relatively 
long period is taken for the water to reach the user, then the danger is 
less than if the amount is small and the avenue of travel and rate of pas- 
sage are brief, because the bacteria of disease are generally short-lived. 

In studying an epidemic of a water-borne disease, it is also advisable 
to make examination of the ice supply, as in some instances intestinal 
disorders have been attributed to the use of ice taken from a polluted 
water. As an example of this the following is quoted from Professor 
George C. Whipple's book on Typhoid Fever: "One of the most 
important cases was that of the St. Lawrence State Hospital at Ogdens- 
burg, N. Y., in 1902, when 39 cases of typhoid fever occurred. The 
ice there used was unquestionably contaminated and in all probability 
infected with fecal matter from typhoid fever patients. Lumps of 
dirt were found frozen into the ice and it was alleged that typhoid 
bacilli were also found." 

These important factors must be kept clearly in mind while deter- 
mining official action regarding a water when checking over the ana- 
lytical data. 

The chemical and bacteriological examination of samples of water 
cannot give results which enable the interpreter to state that the 
pollution is either specific or non-specific; therefore the most critical 
dangers to a water supply cannot be determined solely from the results 
of laboratory examinations. They can only be determined by r personal 
investigation or a thorough examination of the w T hole system with full 
knowledge at hand of the presence or absence of water-borne diseases 
on the w T ater shed. 

The laboratory examinations are often of much value in determining 
to some extent the following points : 

The vegetable origin of contamination. 

The animal, including human origin, of pollutions. 

The relative amounts of such contaminations and pollutions. 

The directness of such contamination and pollution when the latter 
is, or has been, present in considerable amount. 

Thus it is to be borne in mind that these examinations can furnish 
data of a general character regarding a water, but this information 
alone will not generally be sufficient to warrant basing upon it a 
decision as to the potability of that water. 

Furthermore, a single examination of a series of samples collected 
at one time furnishes information only of conditions at that time; 
and if the supply is liable to fluctuate in either amount or character, 



SANITARY WATER ANALYSIS 409 

then new conditions may be created, and the possibility of such fluc- 
tuations or changes cannot' be determined by a single or even from a 
number of examinations. 

This necessitates then, a constant supervision of a water supply 
which is subject to pollution whether it be direct or indirect. 

SANITARY WATER ANALYSIS. 

The standard methods as compiled and revised by the committee 
of the American Public Health Association, the American Chemical 
Society and Officials of Agricultural Chemists are recommended for 
use in the examination of water and sewage. These methods are 
published in book form and can be obtained from the American Public 
Health Association, 113 Market Street, Lynn, Mass. 

In outlining the determinations that are made in a water analysis 
with the interpretation of their results, the writer does not claim to 
introduce any original ideas here, but desires to give the plan that has 
been accepted by the Committee on Standard Methods, and to use 
the accepted terms and phrases commonly expressed by well-known 
authorities on water supply. Unless some such standard or a recogni- 
tion of a definition of the terms and phrases so used, be accepted, it is 
difficult to instruct the reader how to properly interpret a water 
analysis. 

When a complete sanitary analysis of a water is made, it covers: 

1. A physical examination to determine color, turbidity, odor and 
taste. 

2. A microscopic examination to determine the numbers and char- 
acter of particles in suspension, especially alga?. 

3. A chemical analysis to determine the nature and amount of 
chemical impurities. 

4. A bacteriological examination to estimate number and kind of 
bacteria. 

5. A sanitary survey of water-shed, including methods of collecting, 
handling, storing and distributing the water. 

The object of a sanitary chemical analysis is not to determine the 
amount of certain compounds of carbon, hydrogen and nitrogen in 
the water because these compounds are in themselves not dangerous, 
but to determine the absence or presence of, and, if present, the 
amount of such compounds as will aid us in tracing the. past history or 
the present condition of the particular water that is being studied. 

For this purpose we determine the amount of organic matter, living 
or dead, that is suspended or dissolved in the water, the amount of 
certain of the products of decomposition of organic matter, and the 
amount of certain minerals dissolved in the water. 

Each class of waters has its own characteristics. The significance 
of any given factor must be judged separately for each particular case. 

Physical Examination and Interpretation of Results. — Odors in 
water are very objectionable. As a rule the most objectionable ones 



410 WATER SUPPLIES AMD THEIR PURIFICATION 

develop in surface waters and are caused by the growth of alga, 
diatoms, protozoa and other microscopic beings. In the case of deep 
wells, hydrogen sulphide and other inorganic compounds may give 
odors to the water. Odors and tastes develop in impounding reser- 
voirs from stagnation and putrefaction of organic matter. 

Certain organisms can be distinguished by their odor, as the "fishy" 
odor of uroglena, "aromatic" odor of asterionella and "pig pen" odor 
of anabana, which is one of the blue green alga. Odors caused by 
undecomposed organisms are due to compounds of the nature of essen- 
tial oils. Alga are responsible for bad tastes and odors in water. 

Removal of tastes and odors may be accomplished through various 
means of aeration and by treatment with copper sulphate. 

Color in water is usually from a vegetable origin, such as dead leaves, 
bark or roots. If the water contains iron, it will be perfectly clear on 
coming from the ground, but will soon turn a rusty yellow color, caused 
by oxidation of soluble ferrous salts to insoluble ferric salts. 

Removal of color may be brought about through storage, because 
of bleaching action and precipitation. Different means of aeration 
are also used. Coagulants, such as aluminum sulphate, iron and lime, 
are added to water containing color. The chemicals combine with the 
coloring matter and form a precipitate which drops out of suspension, 
leaving a clear supernatant liquid. 

Turbidity is synonymous with muddiness, usually due to clay or 
silt. This may also be removed by the use of a coagulant, or, if the 
turbidity is sufficiently coarse, it may be filtered out without previous 
chemical treatment. 

Reaction. — The alkaline reaction of natural waters ordinarily depends 
upon carbonate and bicarbonate of calcium and magnesium. The 
incrustants are caused by the sulphates, chlorides, nitrates and silicates. 
Acid constituents are represented by aluminum and iron sulphate. 

Water Softening. — The carbonates represent the temporary hardness 
and are removed by boiling, and also by the addition of lime. The 
sulphates and chlorides cause a permanent hardness, and are removed 
by the addition of sodium carbonate. However, there are certain 
commercial compounds that are used at the present time, which give 
much satisfaction in water softening. 

Chemical Analysis. — According to standard methods, results are now 
expressed in parts per million (p. p. m.). One milligram in 1000 c.c. 
equals 1 part per million. One part per million equals 0.058 grains 
per U. S. gallon. 

The total solids furnish an index of the total quantity of foreign 
impurities and further furnish a rough index of the relative quantity 
of inorganic and organic substances which make up the inorganic 
matter. 

Organic Matter. — Organic matter in the soil and that passing through 
it with the ground water is of two main kinds, carbonaceous and 
nitrogenous. These may become oxidized C0 2 CH 4 , and H 2 . These 
end-products are rarely reached in nature as the result of decomposition 



j 



SANITARY WATER ANALYSIS 411 

of organic matter in the soil. Carbonaceous matter comprises the 
cellulose bodies. These may be oxidized to carbon dioxide. The 
nitrogenous matter comprises albumins, the waste of animal life, and 
proteids. These may be oxidized to nitrates. The organic matter in 
itself is not dangerous to health, but is undesirable because it putrefies 
and thus gives the water disagreeable tastes and odors; besides this, it 
offers food for bacterial growth. 

Nitrogen. — Most of the difficulties in securing a satisfactory water 
supply are connected with the cvcle of nitrogen in its relation to organic 
life. 

Nitrogen is found as an essential constituent of all living matter. 
When thus combined it is called organic nitrogen, and is found in 
undecomposed vegetable substances. As soon as dead these substances 
become food for microorganisms. 

Nitrogen is determined as: (1) total nitrogen; (2) nitrogen as free 
ammonia; (3) nitrogen as albuminoid ammonia; (4) nitrogen as nitrites 
and (5) nitrogen as nitrates. 

Nitrogen as Albuminoid Ammonia is an approximate measure of 
nitrogenous organic matter from two sources, vegetable and animal 
proteids, and amino bodies from vegetables are much more stable than 
from sewage and evolve nitrogen less rapidly. The amount is there- 
fore an index of pollution. Organic matter of animal origin yields 
a larger amount than of vegetable origin. As a rule the albuminoid 
ammonia in a surface water should not exceed 0.3 p. p.m. and ground 
water as a rule not more than 0.15 p. p.m. 

Nitrogen as free ammonia is the result not only of decomposition of 
nitrogenous organic matter, but is also formed during the process of 
denitrification, by which nitrates are again reduced to nitrites and 
nitrities to ammonia. 

In a surface or ground water free ammonia represents one of the 
latter stages of putrefaction of organic matter; thus, the bacteria 
decomposition of sewage yields large amounts of " ammonia. The 
ammonia itself ordinarily found in drinking water is harmless; its 
significance lies in the fact that it indicates the presence of putrefying 
organisms. 

Its presence in clean and properly stored rain water has much less 
significance than in a surface or ground water. 

Deep well waters of exceptional purity and practically sterile, may 
contain a relatively high percentage of free ammonia. This is sup- 
posed to come from a chemical reduction under high pressure and 
perhaps temperature of the geological nitrogenous matter in coal 
and alluvial deposits. In general, free ammonia is less of a danger 
signal than the albuminoid ammonia. More than 0.15 p. p.m. must 
be regarded as suspicious. 

Nitrogen as nitrites is an indication that either oxidation of organic 
nitrogen or decomposition of nitrates is taking place. It represents 
the transitional stage of oxidation of organic matter between ammonia 
and nitrates and therefore indicates incomplete oxidation of the protein 



U2 WATER SUPPLIES AND THEIR PURIFICATION 

and the active growth of bacteria. As a rule, pure water contains no 

nitrites, or only traces. However, nitrites may be absent from an 
impure water owing to the fact that the oxidation has not reached this 
stage or, perhaps, has entirely passed it. The absence of nitrites, 
therefore, does not mean that the water is necessarily safe, wdiile their 
presence in any but the smallest measurable amounts shows pollution. 
Usually high free ammonia values and high nitrite values go hand in 
hand, as both processes are usually going on simultaneously. Nitrites 
are a danger signal in the same sense that the colon bacillus is a danger 
signal, indicating pollution but not necessarily infection, for they do 
not tell the source or nature of the organic matter. 

Nitrites are not only formed by the nitrifying bacteria in the soil 
from the ammonia, but are also formed from the denitrification of 
nitrates by a variety of microorganisms. The typhoid bacillus, the 
colon bacillus and many other bacteria have the power of producing 
nitrites in culture media. 

Nitrates. — The final step in the mineralization or nitrification process 
is the conversion of nitrites into nitric acid, which combines with a 
base to form nitrates. In the form of nitrates, the nitrogen is com- 
pletely mineralized and nature's cycle of conversion has been com- 
pleted. Their presence, therefore, signifies past or distant pollution, 
while the absence of nitrates does not necessarily indicate their pres- 
ence and on the other hand, does not necessarily indicate immediate 
danger. If the water contains an appreciable quantity of nitrates and 
no nitrites, it shows that the sources of pollution have been distant, 
and that the organic matter has been completely oxidized. In waters 
considered pure the nitrates are rarely less than 0.3 part, or may run 
as high as l.G parts, per million according to some authorities. A 
water may contain a large amount of nitrates and also a considerable 
amount of free ammonia and nitrites. Such a water has been incom- 
pletely purified and usually contains a considerable number of bacteria, 
and if some of these are of human origin the water is, of course, unsafe. 

On the other hand, there may be a large amount of nitrates and free 
ammonia, and nitrites be practically absent. Such a water would be 
one that had at some time been badly polluted with organic matter, 
but this material has been mineralized by the purification processes. 
Waters in this condition generally show low bacterial counts and the 
absence of fecal organisms, but it requires a high degree of purification 
to completely remove the fecal bacteria, and consequently the danger 
of infection. 

Chlorine. — The organic matter found in water is not stable, but is in 
a state of transition until it is completely mineralized; but the com- 
pounds of chlorine are very stable, and when they once gain access to 
water they remain to bear witness against it and to serve as a tell-tale 
of past bad associations. It is because of this fact that so much 
significance is given to the chlorine content of water. 

The legitimate sources of chlorine in natural waters are from the 
sea and from the natural deposits of salt that are the remains of pre- 



SANITARY WATER ANALYSIS 413 

historic seas. Storms break up the waves into spray, which is carried 
inland by the wind currents and with it small particles of salt. This 
spray is washed down by the rain, so that all surface water contains 
some salt. The quantity is quite proportional to the distance from the 
sea coast, so that several hundred miles inland it is only present in small 
quantities, while near the sea coast the quantity is considerable, so 
that where it is not a natural constituent of the earth, as in the salt 
regions of New York State, the normal amount of chlorine for a surface 
water from any given locality can be quite accurately determined, and 
any excess above this amount is an indication of pollution by animal 
or human wastes. 

Salt being used in the domestic animal diet and to a much larger 
extent in the human kitchen, is therefore found in the animal and 
human wastes; and when such wastes reach a water, the presence of 
this excess chlorine will indicate animal or human pollution which may 
have been completely mineralized, yet the chlorine remains to show 
what has been the condition in the past. 

It has been estimated that chlorine content in the annual drainage 
of any water-shed is increased one-tenth part per million per twenty 
inhabitants per square mile. 

The mixture of even a small proportion of sea water renders the water 
hard and salty and undesirable for domestic use. The writer has had 
an extensive experience with the mixture of sea water and fresh water 
at Miraflores, Canal Zone. It was found there, that a water contain- 
ing 60-70 parts per million of chlorine caused trouble with the boilers 
and this particular water supply was later abandoned. 

Oxygen consumed is synonymous with oxygen required and oxygen 
absorbed. This is a measure of carbonaceous organic matter which 
is partly oxidized by KMn0 4 solution. Water which oxidizes rapidly 
usually contains unstable carbonaceous matter. Oxygen consumed is 
closely related to color. 

Dissolved oxygen represents the degree of aeration or oxygenation 
of water. The amount of oxygen in solution is fairly constant in waters 
of uniform composition freely exposed to the air. Water containing 
sewage and other oxidizable matters uses up the dissolved oxygen. 

The absence of dissolved oxygen permits the growth of anaerobic 
organisms that cause putrefaction and impart putrid tastes and odors 
to waters. 

The amount of oxygen found in the water of a running stream taken 
at different points may furnish valuable information as to the rapidity 
with which the process of self-purification is taking place from a chemi- 
cal standpoint. When the dissolved oxygen is used up, the fish die off. 
Gasch, Marsson and Hofer have found undoubted evidences of a close 
relation between an insufficient amount of dissolved oxygen and fish 
diseases of both a parasitic and bacterial nature. If dissolved oxygen 
is absent from ground water, sulphates may be reduced to sulphides 
and hydrogen sulphide set free. 



414 WATER Sir PLIES AND THEIR PURIFICATION 

Carbonic acid may exist in water in three forms: free carbonic acid, 
bicarbonate and carbonate. The carbonic acid of the carbonate plus 
half that of bicarbonate is known as the " bound carbonic acid.'' 

Carbon dioxide from decomposition of organic matter is first of 
importance in ground waters. It greatly increases the solvent action 
of water which may cause corrosion of the water pipes. 

Iron in water influences its quality from the standpoint of desirability 
rather than from the standpoint of health, and after hardness there is 
no question of greater practical importance in considering the quality 
of a water. All natural waters contain a certain amount of iron and 
ground waters are apt to contain it in objectionable amounts, which, 
with the presence of organic matter, promotes the growth of crenothrix. 
This organism is very troublesome in water pipes. The solution of 
the iron is brought about by the organic matter. The iron exists in 
the soil as ferric compounds. These are reduced by the organic matter 
to ferrous salts, which are soluble in water containing carbonic acid. 
AY hen ground waters containing iron are first drawn they look clear, 
but the ferrous salts in solution are soon oxidized on contact with the 
air to insoluble ferric salts, which are precipitated as red oxides. 

Iron Removal. — One part per million of oxygen, oxidizes 7 parts 
of iron. Acids, organic matter and manganese interfere with the 
precipitation of ferric hydrate. Most of the carbon dioxide must be 
eliminated. Aeration for removal of iron is applied in several ways 
by foundations, pre-filters, which consist of a very coarse filtering 
medium; sunlight also assists in the precipitation of iron. 

Lead. — Chemical tests for lead should be made. No water should 
be used for drinking purposes containing even a trace of lead. The 
source of lead in the water is almost always from lead service pipes or 
some other object used in collection, storing or delivering the water. 

Microscopic Examination. — The main object of the microscopic 
examination of water is to determine the presence or absence of those 
microorganisms which produce objectionable tastes and odors. The 
determination is also of value as an index of pollution. The organisms 
comprise the Diatomacese, Chlorophyceae, Cyanophycese, Fungi, 
Protozoa, Rotifera, Crustacea? and other minute organisms not includ- 
ing bacteria. 

The microscopic examination may be considered in five parts: 

1. Indicating sewage contamination when such organisms as Beggia- 
toa and miscellaneous objects as yeast cells, starch grains, fibers of 
wood and paper, threads of silk, etc., are noted. 

2. As indicating progress of self-purification of streams by noting 
changes in the character of microscopic organisms. 

3. Explaining chemical analysis. Large amounts of albuminoid 
ammonia might show a large amount of living sewage pollution. Pos- 
sibly the sudden decrease in nitrates may be caused by some micro- 
scopic organisms using the nitrogenous food. 

4. As explaining the cause of turbidity, odors, etc. This has been 
explained under the heading of odors earlier in the chapter. 



SANITARY WATER ANALYSIS 415 

5. As a means of identifying the source of a water (in special cases). 
The presence of certain microscopic organisms in water gives a clue to 
its origin. In this way the presence of a surface water may be detected. 

6. As a method of studying the food of fishes, oysters, and other 
aquatic organisms. Where there are no plankton, there is no fish. 
Plankton refers to minute floating animals and plants that are drifted 
about by waves and currents. 

Limnology is that branch of science that treats of lakes and ponds, 
their geology, geography, physics, chemistry, biology, and the relation 
of these to each other. 

Temperature which is taken by means of a thermometer or ther- 
mophone, together with the study of dissolved gases, are very important 
items to be considered. 

High excess of chlorine seems to accompany heavy growths of 
organisms. 

Seasonal Distribution. — During the winter the lake will contain very 
few organisms. 

Horizontal Distribution. — Under this heading we have: Littoral 
organisms which include all those forms that are attached to the shore 
or to plants on the shore. Limnetic organisms are those that make 
their home in the open water. 

Vertical Distribution. — The protozoa as a class seek the upper strata 
of water. 

Removal of growths was taken up under the heading of odors. 

Bacteriological Examination of Water. — The number of bacteria is 
not as important as the kind; however, the number corresponds to the 
amount of organic pollution . Different temperatures are used for grow- 
ing the bacteria as they do not all grow at the same temperatures. 
Pathogenic bacteria do not grow, as well as saprophytic varieties at 
20° C, and the latter often do not grow at all at 37° C. A water 
containing great numbers of bacteria when counted upon gelatin or 
nutrient agar at 20° C. and but few colonies upon agar at 37° C. has 
little sanitary significance, while the reverse would be looked upon 
as suspicious. The distinction between polluted waters and waters 
of good quality is more sharply marked by counts at 37° C. than 
is the case with counts at 20° C. Also, the results from the plates 
grown at a higher temperature are available in a much shorter time. 

The determination of the number of bacteria in water is of great value 
when studying surface waters, such as lakes and rivers. As a rule, the 
number of bacteria is proportional to the pollution of the river, not 
necessarily fecal matter but pollution from any dead organic matter. 
A river contains more bacteria in winter than in summer, or we might 
say that the number of bacteria in a stream is an index of its turbidity. 
The numerical determination is also useful in determining leaks in a 
water supply. It is also useful in determining the efficiency of a filter. 

In the routine bacteriological analysis of a water we do not attempt 
to isolate the specific typhoid organisms but only those organisms which 
have a fecal origin, and some of the reasons for this follow. 



416 WATER SUPPLIES AND THEIR PURIFICATION 

What is not a natural habitat for typhoid bacilli, and the majority 
of them probably die off in a short time. As there is a period of 
incubation between the infection and the recognition of the disease, 
it is possible in water-borne cases for the typhoid bacilli to have dis- 
appeared from the water before the disease has been recognized. 

If the source of the water was a flowing stream and the infection was 
occasional and not constant; the search for the organism would, of 
course, be useless. Under such conditions, even if our laboratory 
technic were perfect, we would not be able to prove our case. 

The typhoid organism has been occasionally isolated from water 
supplies; but the laboratory technic is not simple, and the practical 
difficulties are such that we know of no laboratory which attempts it 
as a routine procedure. 

B. Coli Communis. — In water laboratories the isolation of the bacilli 
of the B. coli communis type is the routine procedure. These organ- 
isms are normal inhabitants of the intestinal tracts of man and of warm- 
blooded animals. The inference is that as they have an intestinal 
origin their presence indicates fecal matter, and some of these feces, 
if of human origin, may at times contain typhoid organisms. 

If the laboratory examinations show organisms of the B. coli com- 
munis type to be absent, we can definitely say that the water is safe; 
but if the examinations show that they are not entirely absent, we 
could not definitely say that the water w r as dangerous. As we are not 
able to differentiate between the organisms of human and of animal 
origin, the mere presence of a few bacteria of the B. coli communis 
type does not necessarily indicate pollution from human beings, as 
they might be entirely of animal origin, coming from pasture lands or 
fertilized fields; but if the organisms are persistently present in small 
volumes of the water, say in 1 c.c. or less, the water should be con- 
sidered unsatisfactory, for even though most of the organisms may be 
of animal origin they are generally accompanied by those from human 
wastes. 

Therefore it is the number of B. coli found in a ground w r ater, as in a 
surface water, rather than the mere presence, which is of sanitary 
importance. 

That the mere presence of B. coli proves the presence of infinitely 
rarer disease germs is inconceivable (Flinn, Weston and Bogert). 

The permissible numbers of B. coli in a ground water is difficult to 
determine. As a rule B. coli should not be present in 1 c.c. samples 
of water, nor in more than 20 per cent, of 10 c.c. samples. It will 
rarely be found in the best ground water even in 100 c.c. samples or 
in more than 10 per cent, of 10 c.c. samples from most undeniably safe 
sources. Waters from peaty deposits show B. coli. 

Presumptive Tests for the ('ohm Bacillus. — These tests are sometimes 
used to determine the presence of B. coli and while unreliable, some- 
times afford useful information. This is merely the water grown in 
lactose bile or lactose broth fermentation tubes. If gas is obtained 
confirmatory tests should be made by plating out on different kinds of 
media. 






TREATMENT OF WATER SUPPLIES 417 

if large numbers of B. coli are present gas often forms in a few- 
hours. Small numbers of somewhat attenuated B. coli may require 
three days to form gas. Attenuated B. coli does not represent recent 
contamination and all B. coli not attenuated grow r s readily in lactose 
bile. No other organism except B. Welchii gives such a test in lactose 
bile. B. Welchii is of rather rare occurrence in water, is of fecal origin, 
is almost invariably accompanied by B. coli and w r hile the sanitary 
significance is the same, it may, if desired, be distinguished from B. coli 
by a microscopic examination of the bile solution w r hen long strings of 
much larger bacilli than B. coli are seen, as w r ell as spores. 

The specific organisms that are found in w r ater and may cause their 
corresponding diseases are B. typhosus, cholera vibrio, dysentery 
bacillus, certain forms of ameba causing amebic dysentery, tubercle 
bacillus. 

Sanitary Survey. — The preceding discussion of sanitary w T ater 
analysis makes it quite evident that, except in those cases where fecal 
pollution is entirely absent, a sanitary analysis can seldom definitely 
establish the fact that a given sample of .water is from a supply which is 
either entirely safe or absolutely dangerous. It can point out probable 
danger, and as such is an aid to be used in connection with other sources 
of information. 

When we speak of a sanitary survey we mean the obtaining of the 
actual knowledge of the physical conditions surrounding the source of 
the sample, the possible sources of pollution, the geology of the water- 
shed, the slope of the ground, etc. In order to make as accurate deter- 
minations as possible, it is absolutely necessary to have this knowledge. 
Samples that are sent into the laboratory should always be accom- 
panied by all possible information as to the history and source of the 
water. 

Single or occasional determinations of either the chemical or bacterial 
constituents of a w r ater are of little value. In fact, it is often mislead- 
ing, especially in surface w T ater. 

A river w r ater may require repeated examination extending over long 
periods of time. A routine bacteriological analysis shows pollution 
but does not prove infection. However, the bacteriological analysis 
tells us more of the present state of the water Avhile the chemical refers 
more to the past state. A sanitary survey of the catchment area is 
frequently of much greater practical importance than all the informa- 
tion furnished by the laboratory. By a sanitary survey we are able 
to discover the sources of contamination, the kinds of pollution, and the 
degree. 

TREATMENT OF WATER SUPPLIES. 

Most of the early efforts toward w r ater purification had for their 
purpose the removal of suspended materials, which rendered the water 
offensive to sight or taste, and it w^as not until the demonstration of 
the Altoona, Germany, filters during the cholera epidemic in the city of 
Hamburg in 1892, that the remarkable hygienic efficiency of sucl/efforts 
27 



41S WATER SUPPLIES AND THEIR PURIFICATION 

was suspected or even appreciated. Since then the introduction of 
water purification plants have progressed by leaps and bounds through- 
out the world. In 1916 it was estimated that in the United States 
30,000,000 people were being supplied with water either filtered or 
sterilized, or both. This progress has been greatly stimulated by the 
popular regard of the germ theory of disease, the published record of 
water-borne epidemics and the great advance during recent years of 
the bacteriology of water supplies. 

The wonderful results that have been obtained by the use of liquid 
chlorine in the disinfection of water supplies, has brought the develop- 
ment of water purification to a very high point. 

Among the various methods used in the purification of water supplies 
are the following : 

1. Clarification. 

(a) Aluminum sulphate. 
(6) Iron and lime. 

2. Filtration. 

(a) Slow sand filters. 

(6) Mechanical rapid gravity filters. 

(c) Drifting sand filters. 

id) Pressure filters. 

3. Sterilization. 

(a) Chlorine. 

(6) Copper sulphate. 

(c) Ultraviolet ray. 

(d) Ozone. 

Classification. — In purifying waters carrying large amounts of clay 
particles, or waters with a large amount of coloring matter, it is cus- 
tomary to use a coagulant, such as aluminum sulphate alone, or a 
combination of iron and lime. These chemicals coagulate the clay 
particles and also form a chemical compound with the coloring matter 
which causes it to form a precipitate, or what is known commercially 
as a "floe" or drops out of solution and falls to the bottom of the 
sedimentation basin, leaving a clear supernatant liquid. All waters 
that are very turbid and contain much coloring matter, must be treated 
in this manner before filtration. 

Filtration. — Slow Sand Filters. — Slow sand filters have been popular 
until a few years ago. The most elaborate plants of this type are at 
Albany, Washington, Philadelphia, Providence, etc., where the waters 
treated are relatively much less in turbidity. 

This type of sand filter is of English origin and consists of a bed of 
selected sand 2\ feet to 5 feet in depth, resting on 12 to 15 inches 
gravel of about \ .to 1 inch in diameter, underlaid with open jointed 
tile or drains. The water to be treated is applied until the bed is 
well covered and thereafter at substantially uniform rates of from 
two to five million gallons per acre daily for a period of usually from 
three to four weeks, when the filter is taken out of service and cleaned 
by scraping off the film of intercepted impurities which has accumu- 



TREATMENT OF WATER SUPPLIES 



419 



lated on the top of the filter from the water. This film of protozoa, 
bacteria and microscopic plants increases the efficiency of the filter 
and it is largely due to this film that the biological changes in the 
organic impurities take place. The higher the temperature of the 
water the greater the activity of the organisms. At temperatures 
below 40° F. the changes produced are negligible. The water which 
is collected from the under-drain is relatively pure and unless pre- 
viously polluted with discharges from human beings will require 
no further treatment. Where such a previous pollution is known 
to have occurred, it is usual to chlorinate the water before or after 
filtration. Filters of this type are usually constructed in units of 
about one acre each and are covered with masonry roofs where the 
winter temperature is sufficient to produce thick ice. 




Fig. 61. — Partial vertical section of one form of filter bed. (Harrington.) 

Mechanical Filters. — The rapid sand filter, known as the mechanical 
filter, is of American origin and has been used since about 1880. 

It differs from the slow sand filter in its rate of filtration, from 125 
to 150 million gallons per day. They were primarily intended to 
remove evidences of turbidity, and are used in conjunction with 
coagulation and sedimentation. 

The filter consists of a tank made of wood, steel or concrete in which 
is placed the filtering material which rests on a system of strainers and 
under-drains for collecting the filtered water. 

The filtering material consists of about 12 inches of graded gravel on 
top of which is placed 30 inches of graded sand. 

The water which has previously been treated with a coagulant and 
has passed through a sedimentation basin, is allowed to flow on to the 
filter bed through a system of troughs, by gravity. When the filters 
become clogged, they are put out of commission and washed. First 
the water is drained down to the surface of the sand, then in some 
instances, compressed air is turned on from beneath, to agitate the 
sand bed and break up any hard mats of dirt. Then the air is turned 
off, and water turned on from beneath the bed of filter to wash out the 
dirty material into the sewer. After sufficient washing, the filter is 



420 



WATER SUPPLIES AND THEIR PURIFICATION 



again put into commission, allowing the filtered water to go to waste 
for a few minutes, before turning it into the clear water well. Examples 
of this type are: Cincinnati, Ohio, New Milford, New Jersey, St. 
Louis, Missouri, Panama, Grand Rapids, Michigan (see Fig. 62) and 
many others. 

Pressure Filters. — Another type of a mechanical filter is the pressure 
filter. It consists of a closed tank with a filter bed similar to the above 
type, and is operated by admitting the settled water under pressure. 
As this filter is closed, it is impossible to see what is going on and for 
that reason cannot be given the proper attention. 




Fig. 62. — Operating floor of rapid mechanical filtration plant, Grand Rapids, Mich. 
(Courtesy American City Magazine.) 



This type of a filter is useful for small supplies, as on private estates 
or for swimming pools, but is too expensive and not efficient enough 
for municipal water supplies. 

Sterilization. — The third method of purification of water known as 
sterilization is brought about by the use of a disinfectant in the water. 
This may be by some form of chlorine: copper sulphate, which is 
nowadays seldom used except as an algicide; the ultraviolet ray and 
ozone, efficient but at the present time too expensive and imprac- 
ticable for municipal supplies. 

Chlorine. — Chlorine is the most important of all disinfectants that 
are used in the purification of water supplies. 

It is formed by the electrolytic decomposition of salt solutions. 
The moist gas evolved from the electrolytic cells being dried and com- 
pressed into liquid and shipped in steel cylinders of approximately 100 
pounds capacity. 

The history of the development of chlorine, in its application as a 



TREATMENT OF WATER SUPPLIES 421 

disinfectant to water supplies, reveals probably one of the most 
important as well as interesting uses for this gas. 

The germicidal power of calcium hypochlorite, commonly called 
" Bleach" has been known since the early fifties. Among the first 
pieces of work that was done in regard to the sterilization of water, by 
the process of chlorination was that which was undertaken in 1905 
by Dr. A. C. Houston, of the Metropolitan Water Board of England, 
using sodium hypochlorite with gratifying results. 

In this country the first attempt to use this process on a large scale 
was at Bubbly Creek Filtration Plant, Union Stock Yards, Chicago, 
Illinois. At this place, calcium hypochlorite was used, and the results 
accomplished brought about the acceptance of this process as a very 
important method of water purification. 

Following the Bubbly Creek experiments, a chlorination plant using 
hypochlorite was installed at several places, among which the most 
important w T as that at Jersey City. 

The use of liquid chlorine began to supplement hypochlorite in 1910, 
owing to the development by Messrs. Wallace & Tiernan, of an 
apparatus necessary for this application to water supplies. The per- 
fection of the apparatus resulted in a rapid use of liquid chlorine in 
the sanitary field to sterilize water and sewage. Much work has been 
done by Professor Earle B. Phelps in regard to the effective use of 
chlorine in treating sewage. 

Liquid chlorine is a far more efficient and economical sterilizing agent 
than chloride of lime. Some of the advantages being as follows: 

Liquid chlorine is an absolutely pure chemical and is placed on the 
market in small cylinders which require very little space for storing 
while chloride of lime is very bulky and requires much greater space. 
Chloride of lime deteriorates rapidly, whereas liquid chlorine retains 
its full efficiency indefinitely. This is of special advantage where 
small installations are made. 

Under working conditions due to unavoidable waste of bleach, one 
pound of liquid chlorine is equal in sterilizing value to from 6 to 8 
pounds of chloride of lime. The sterilization is more uniform and 
better bacteriological results are obtained. Also water treated with 
liquid chlorine is less liable to have taste or odor due to the moie accu- 
rate control. Liquid chlorine control apparatus requires little more 
than daily inspection, and insures continuous service, while the appa- 
ratus for the application of chloride of lime requires constant attention 
to prevent clogging of orifices,. The saving accomplished is frequently 
in excess of 50 per cent. 

Description of Apparatus. — The chlorinating apparatus regulates the 
flow of chlorine gas and applies it where needed. Upon releasing the 
pressure in the cylinder, the chlorine changes from a liquid to a gas. 
The gas passing from the cylinder is controlled and measured by the 
apparatus and introduced into the water or sew r age in proper propor- 
tion to effect sterilization. 

There are two general types of chlorinators : one by w^hich the dry 



422 



WATER SUPPLIES AND THEIR PURIFICATION 



chlorine gas is introduced to the water or sewage, and the other by which 
the chlorine gas is first dissolved into a small amount of water and the 
resulting chlorine solution piped to the point of application. These 
two general types are adapted to be operated under manual or auto- 
matic control. 

The amount of chlorine required is dependent entirely upon the 




Feed Water Gaude 
Chlorine Check Valve* 
Solution Jar Head 
Jet Orifice Cleaner. 
Feed Water 
Supply 

Line 

FeedWaterVahe 
Water Pressure 

Reducing Valve 

Strainer 

Globe Valve 
Water Seal 
Water Seal Wast 
Pulsating Meier 
Solution Outlet Tube 
Solution Jar- 
Solution Receiver 
Solution 

Tank Valve 

Chlorine lank 



Solution Valve 
Suction 
Main 



-Tank Pressure Gauge 



Chlorine Control 
Valve 

Pressure 
•-Compensator 

•Compensator Cap 



FlexibleTank Connection 
-AuxiliaryTonk Valve 




Fig. 



63. — Chlorinator, showing how to be operated. (Courtesy, Wallace & Tiernan 

Co., Inc.) 



composition and quality of the water to be treated. It is found, from 
general practice, that a filtered water requires from 0.12 to 0.40 p.p.m., 
spring or well water from 0.20 to 0.50 p.p.m., and raw surface water 
from 0.30 to 1.00 p.p.m. 

Point of Application. — The point of application is of the utmost 
importance in the chlorination of water. The source of supply, method 



TREATMENT OF WATER SUPPLIES 423 

of treatment, distribution, and local conditions influence the point of 
application, and therefore the type of apparatus recommended. 

The following points should be borne in mind : 

A raw, untreated water requires more chlorine for its proper steriliza- 
tion than a filtered or clarified water. 

If a coagulant is used, a saving in chemicals is sometimes effected 
by introducing the chlorine before the coagulating chemical. 

With a filtered water, where possible, chlorine should be applied after 
filtration rather than before. 

Chlorine should be introduced as near to the inlet of the distributing 
system as possible to avoid pollution subsequent to chlorination. 

A chlorine control apparatus should be installed in a substantial 
structure provided with heating facilities to insure a minimum tem- 
perature of 50° F. 

The Action of Bleach When Applied to Water. — The disinfecting 
action of bleach can be most conveniently considered by regarding it 
as a heterogeneous mixture of reactions. 

On dissolving bleach in water, the first action is the decomposition 
of calcium oxychloride into an equal number of molecules of calcium 
hypochlorite and calcium chloride. 

(2) CaOClo = Ca (OCl) 2 + CaCl 2 

Solutions of pure hypochlorite are alkaline in reaction because of 
excess of hydroxyl ions. In solutions of bleach the hydrolytic action 
is retarded by the OH 1 , due to free base, and accelerated by the excess of 
H 1 . The addition of any substance that reduced the OH 1 concentra- 
tion enables hydrolysis to proceed to completion; thus the addition 
of weak acid as boric acid yield a solution of hypochlorous acid. 

The Action of Chlorine When Applied to Water. — When a solution of 
chlorine in water is used as a germicide the chemical reactions that 
occur differ materially from those of hypochlorite solutions. 

The general reactions are of three types: 

1. Oxidation of organic matter. 

2. Direct chlorination of the organic matter. 

3. A bactericidal action. 

If water contains appreciable amounts of organic matter almost all 
chlorine is consumed in first reaction, and even in filter effluents 
oxidation accounts for quite a bit of chlorine consumed. It is this 
reaction that determines the dosage required for effective sterilization. 

In reference to the second reaction, it is more than probable that 
chlorinated derivatives are largely responsible for the obnoxious tastes 
and odors produced in some waters. It has been suggested that these 
were due to the formation of chloramines. 

Very little is known about the nature of the third reaction. It is 
possible that chlorine and chlorine compounds exert a toxic action on 
microorganisms. 

Copper Sulphate. — Copper sulphate has been used to sterilize water 
supplies and very good results have been obtained, especially in the 
Philippines in killing cholera vibrio. 



124 WATER SUPPLIES AND THEIR PURIFICATION 

Its greatest use is as an algicide and as such it gives excellent 
results. It was first used by Moore & Kellerman, of the U. S. Depart- 
ment of Agriculture, in 1903. 

The amount of copper sulphate used depends upon the kind of algae 
present, and a table is given below with the proper amounts. The 
amounts used are so small that there is no possibility of any injury 
to the human consumer, which is further prevented by the fact that 
the copper reacts with any calcium that may be present in the water 
and is precipitated ; 

pounds per million gallons of water. 



Asterionella, 


0.8 


Spirogyra, 


1.7 


Anabamena, 


0.8 


Oscillaria, 


1.7 


Urogelina, 


0.4 


Crenothix, 


2.5 


Beggiatoa, 


41.51 



These quantities apply to water at about 60° F. The quantity to be 
increased by about li per cent, for each degree below this and decreased 
at the same rate for each degree above it. 

Ultraviolet Ray and Ozone. — Ultraviolet ray and ozone are both used 
to a small extent in water sterilization and give a certain degree of satis- 
faction. 

These methods are very expensive and can only be used with a water 
that is very clear and colorless, otherwise sterilization is very poor. 

WATER PURIFICATION IN THE FIELD. 

During the recent w T ar, the purification of water in the field for the 
American Expeditionary Forces was carried on by some means of 
chlorination, which led to the development of the following mobile 
outfits; "Steri-lab," "chloro-pumps" and "mobile-lab." 

The "steri-lab" consisted of a three-ton chassis, carrying a gasoline 
driven pump of double acting piston type, capacity 20 gallons per 
minute, operated against pressure of 100 pounds per square inch, 
50 feet 2-inch hose, a foot valve and strainer. The suction hose is 
put down in a well or stream and water pumped direct to a Roberts 
pressure filter, connected with an alum pot. Chlorine gas was applied 
at pump suction, the dose being heavier than in ordinary municipal 
work, and the surplus chlorine is removed by dechlorinating with 
thiosulphate solution. The filtered and sterilized water passes to a 
discharge valve where it can be fed to tank cart or stationary storage. 
It would sterilize 1200 gallons per hour. In the front part of the truck 
is a well equipped laboratory for all necessary chemical and bacterio- 
logical tests. 

The " chloro-'pum'p" consisted of a If -ton chassis carrying a pump 
with a capacity of 40 gallons per minute and a chlorinating apparatus, 
but no laboratory. 



WATER PURIFICATION IN THE FIELD 



425 



The "mobile laboratory" consisted of a l|-ton chassis carrying a well 
equipped laboratory for necessary chemical and bacteriological tests. 




Fig. 64. — Ready for the road. 



All of these units were found to be most useful in sterilizing water 
for troops and would be very applicable for use with boards of health 
in emergency work or in a construction camp. 




Fig. 65. — The mechanical equipment. 



The Lyster bag was also used and in some instances the water was 
sterilized in the bag. This was done by breaking a small ampoule-of 



426 WATER SUPPLIES AND THEIR PURIFICATION 




Fig. 66. — Chlorinator in laboratory. 





1 1 


-am * 


\ ■ 



Fig. 67. — Equipment in operation. 



WATER PURIFICATION IN THE FIELD 



427 



calcium hypochlorite and dissolving it in the water. There was a great 
deal of dissatisfaction from the use of this method as often the hypo- 
chlorite was found to contain practically no chlorine and it also gave 
the water a taste to which the soldiers objected. 




Fig. 68. — Another view of the laboratory. 

Figs. 64 to 68. — Mobile water purifying and testing outfit used with the American 

Expeditionary Forces in France. (Courtesy of Wallace & Tiernan Co., Inc.) 

Water carried in the carts was often sterilized by use of "Javelle 
water" or bleach. Enough w T as added to the water to show a small 
amount of free chlorine when tested. 



REFERENCES. 



1. Standard Methods for the Examination of Water and Sewage. 

2. Engineering News-Record, 1917, p. 18. 

3. Flinn, Weston and Bogert: Water Supply Handbook. 

4. Rosenau, M. J.: Preventive Medicine and Hygiene. 

5. Scientific Publications, Wallace & Tiernan Co., Inc. 

6. Race, Joseph H.: Chlorination of Water. 

7. Dakin and Dunham: Handbook of Antiseptics. 

8. Phelps, Prof. E. B.: Self-purification of Streams. 

9. Whipple, Geo. W.: The Microscopy of Drinking Water. 



CHAPTER XVI. 

SEWAGE AND WASTE DISPOSAL. 

By JAMES T. B. BOWLES, B.S. 

SEWAGE. 

Introduction. — In discussing this subject the writer has endeavored 
to carry out the same ideas as those under the subject of Water 
Supplies and Their Purification ; that is, he has used not only the 
results obtained from his own investigations, but he has tried to bring 
out the approved theories of others, that have been developed on 
this subject and in so doing has used the definitions of terms which 
are generally accepted by all workers. 

The term sewage is taken to mean the solid and liquid water, wastes 
from human habitation and manufactories, including slaughter nouses, 
etc., diluted with the water used. It is quite obvious that sewage 
varies greatly for different periods of day and night and according to 
the character of the community. 

The decomposition of organic material without the production of 
offensive odors is accomplished by bacterial life naturally present and 
when provided with sufficient quantities of oxygen. The rapidity of 
such decomposition depends upon whether the oxygen can be immedi- 
ately brought into intimate contact with all parts of the organic matter 
or whether disintegration or molecular change must first occur. This 
is known as aerobic decomposition. The decomposition of organic 
materials by bacteria naturally present and which do not require 
oxygen is the more rapid process of disintegration, and this is usually 
accompanied by the production of foul and offensive odors. This is 
known as anaerobic decomposition. 

The disposal of human excreta in rural districts where it is impossible 
to use a modern sewer system is a very vital problem. The old- 
fashioned country privy for the disposal of. excreta has been not only 
very disgusting and a great nuisance, but also a vast disseminator 
of typhoid fever, dysentery and hookworm. Filth seeps and soaks 
through the ground and contaminates wells and springs. 

The United States Public Health Service and the various State 
Boards of Health have designed different types of sanitary privies, 
which have been of great service to the rural communities; the general 
idea being to have a water tight, concrete vault and that it be well 
ventilated; fly proof, and easily accessible for cleaning. The vault is 
divided into two portions, so that when one is filled the other side can 
be used while it is being cleaned. In some instances dry earth or sand 
is thrown into the vault occasionally to absorb the liquid portion. 



SEWAGE 429 

When necessary to be cleaned the excreta is removed and buried in 
shallow furrows. 

For more detailed information in regard to the sanitary privy, see 
references Florida State Board of Health Publications, 1919, and 
Public Health Bulletin, 1918-19, U. S. Public Health Service, Wash- 
ington, D. C. 

The easiest method of disposing of sewage from a town or city is to 
discharge it into a body of water. This is known as the dilution 
method. Here the natural forces that transfer putrescible organic 
material into inorganic and inert material are brought into play. 
This change must be brought about without causing nuisance. 

The factors influencing the successful disposal of sewage by dilution 
are: 

(a) Suspended Matter. — Suspended matter, which, subsiding, forms 
sludge deposits that deplete available oxygen in the overlying water, 
thus producing objectionable conditions. This condition is dependent 
upon the velocity of the current into which the sewage is discharged. 
Velocity less than 3 feet per second may permit this. 

(b) Sufficient Diluting Water. — This should be approximately 6 
cubic feet per second per 1000 persons contributing sewage or a dilution 
approximately 1 to 50. (This figure is dependent upon velocity and 
oxvgen content of diluting water, also character of sewage discharged. — 
G. W. Fuller.) 

(c) Diluting Water to Maintain Oxygen Balance. — While there is still 
oxygen in water containing organic matter the condition of putrefac- 
tion is not possible. The more free oxygen per unit of volume of water 
the greater its oxidizing power. Water saturated with oxygen contains 
at ordinary temperature and pressure about 10 parts per 1,000,000. 
If the sewage contains about 500 p.p.m. of organic matter it is evident 
that 50 volumes of water are required for complete oxidation. 

When dilution is not possible, artificial treatment must be resorted 
to. In the artificial purification of sewage different objects are sought, 
namely : 

(a) To improve esthetic conditions by preventing discharge of offen- 
sive floating matter into a stream. Method of treatment involving 
use of mechanical or physical processes, such as screens, grit chambers 
or plain sedimentation basins. 

(6) To prevent a nuisance (oxidation process, such as filtration). 

(c) To prevent introduction of objectionable bacteria into a stream 
(sterilization, by hypochlorite or liquid chlorine). 

These objects are brought about by the following methods or by 
combination of these methods : 

1. Screening. 

(a) Coarse. 

(b) Fine. 

2. Sedimentation. 

(a) Rapid in grit chambers. 

(b) Slow in settling basin. 
With chemical precipitation. 



•130 SEWAGE AND WASTE DISPOSAL 

(c) Accompanied by liquefaction of solid matter as in septic tank. 
With sludge digestion in separate tank (Imhoff tank) or 

modified Imhoff tank. 
Plain spraying into the air. 

With the aid of sludge from previously aerated sewage 
(activated sludge). 

3. Oxidation by means of filtration. 

(a) Contact bed treatment. 

(b) Sand filters. 

(c) Trickling filters. 

4. Sewage irrigation on farms. 

5. Disinfection treatment with some form of chlorine. 

6. Miles acid process. 

The method or methods to be decided upon depend upon the object 
to be attained, the requirements of the particular situation, the size 
of community and the amount of money to spend. 

In making an analysis of sewage the following determinations are 
usually made (see Standard Methods of Water and Sewage Analysis) : 

(a) The total solids. 

(b) The portion of the total solids that is dissolved. 

(c) The portion of the total solids that is suspended. 

(d) The settling solids (the portion of solids capable of settling out 
in two hours) . 

(e) The mineral matter (the portion of total solids remaining after 
ignition) . 

(/) The organic matters (the portion of total solids lost in ignition). 

(g) Organic nitrogen (a measure of the amount of nitrogenous 
organic matter) . 

(h) Albuminoid ammonia, which is a measure of the less stable 
portion of the nitrogenous matter. 

(i) Free ammonia, the first step in the "nitrogen cycle" — a measure 
of how far and at what rate transition is being made from organic to 
inorganic conditions. 

(j) Nitrites and nitrates (the conversion of ammonia products into 
nitrites and nitrates known as "nitrification" marks the ultimate 
change in the biological purification of sewage). 

(k) Oxygen consumed (a measure of the quantity of organic matter 
in which nitrogen is absent) . 

(Z) Putrescibility tests — to determine if there is a sufficient supply 
of oxygen present to bring about complete oxidation of organic matter 
present. 

It is the organic matter in sewage that causes trouble. The object 
of sewage treatment is to remove it or to convert it into mineral matter. 
When sewage is treated to deprive it of its objectionable features, one 
or both of two fundamentally different processes are employed: 

(a) Actual removal, such as thorough screening. 

(b) Conversion of putrescible matter into stable substances. Sewage 
treatment is usually accomplished in successive steps, the degree of 
purification increasing with each step and with care of operation. 



SEWAGE 431 

Screens. — Various sizes are used, from the coarse rack, that merely 
removes heavy material as rocks, cans, boards, for a protection to 
machinery, to the very fine that supplements sedimentation basins, 
by removing the greater part of the putrescible organic matter. 
The coarse screens are usually stationary, while the fine screens are 
operated mechanically, either on the rotary or the conveyer system. 
Screens are now being used where some partial method of purification 
is essential : 

(a) To remove floating suspended matter that would be objection- 
able to the eye, or that might cause local nuisance. 

(b) Where after chlorination sewage can be safely turned into a 
stream without danger of nuisance or of infecting drinking water. 

Results Accomplished by Screens. — Coarse screens i inch mesh 
remove 5 to 10 p.p.m. (parts per million) suspended matter. 

Fine screens 0.2 inch mesh, remove 25 to 160 p.p.m. suspended 
matter. 

Sedimentation. — Grit Chambers. — Grit chambers are intended to 
remove heavy material, such as sand, gravel, bits of coal and cinder 
known as "grit." It is desirable to eliminate this material to protect 
the pumps from clogging and because it assists in disposal of sludge 
from settling basins. Its removal is accomplished by sedimentation 
in small basins by retarding the velocity of flow through the basin. 
Grit settles according to its size and specific gravity. In general a 
velocity of one foot per second is allowed for subsidence. 

Results Accomplished by Grit Chambers. — Removal of 10 to 40 parts 
per 1,000,000 of suspended matter. 

Plain Sedimentation. — In this process sewage is allowed to stand or 
flow very slowly through tanks where the solids capable of settling 
under existing conditions gradually subside to the bottom and is 
known as sludge. There is no aim to encourage bacterial action or 
to remove the colloidal matter which will not settle unaided in from 
two to eight hours, as this is of no great amount. 

Detention Period. — The heaviest matter settles first; this is fol- 
lowed by the lighter particles. The period may be very short, per- 
haps thirty minutes, but it rarely exceeds two and a half hours which 
is equal to a flow of 120 feet. 

Results Accomplished. — The suspended solids removed depend upon 
the detention period. Usually a detention period of two and a half 
hours will permit a removal of about 65 per cent, of the suspended 
matter. With the longest practical detention periods not much greater 
removal can be accomplished, and Mr. G. W. Fuller states that most 
of the work is accomplished in the first 40 feet of flow, and is effected 
only slightly by temperature. 

Chemical Precipitation. — The old idea of chemical precipitation was to 
remove a greater quantity of the suspended matter by mixing with the 
sewage one or more soluble chemicals, which, reacting with themselves 
or some inorganic substances in the sewage, form a precipitate which 
drags down with it suspended matter. The most common chemicals 
used were ordinary lime, aluminum sulphate, or sulphate of iron. 



432 SEWAGE AND WASTE DISPOSAL 

Results Accomplished. — The results depend upon the quantity of 
chemical precipitant used. In actual practice 50 to 75 per cent, of 
the total suspended matter and 80 to 90 per cent, of bacteria are 
removed. 

Removal of suspended matter by sedimentation and chemical 
precipitation involves another problem, viz., disposal of the sludge 
or settled material which is removed about once a week. This is 
the greatest difficulty in the application of sewage disposal by chemi- 
cal precipitation. The attendant expense has prevented its general 
adoption and has even caused its abandonment where originally 
installed. The desire to diminish the attendant problems of sludge 
disposal has led to the development of various types of sedimentation 
tanks that aim to further sludge digestion. For ordinary sewage this 
method has passed away. 

Miles' s acid process consists of precipitating the sewage sludge by 
adding sulphuric acid, in order to obtain grease from the sewage; the 
remainder of the sludge to be used for fertilizing purposes. This has 
not been tried on a very large scale but on small experiments and with 
certain types of sewage has given fairly good results. See report city 
of New Haven, Conn., 1918-19. 

Septic Tank. — This process, aside from the physical sedimentation 
of solids depends upon anaerobic bacterial action. This anaerobic 
bacterial action or septicization causes a breaking down of the com- 
plex substances into simpler ones. Insoluble substances are also 
changed into soluble ones as a result of bacterial activity through 
enzymes. (See reports Massachusetts Institute Technology Sewage 
Experiment Station.) The primary object of this tank is sedimenta- 
tion, the period varying from eight to twenty-four hours. Sedimen- 
tation takes place in contact with decomposing sludge. The decom- 
position of the sludge is accompanied by the production of gas and a 
reduction in the quantity of sludge. 

Results Obtained from Septic Tanks. — Thirty to 70 per cent, of the 
sludge by volume is converted into gas. Reduction in weight of solid 
matter is from 40 to 50 per cent. All the settling solids and a por- 
tion of the colloidal solids are removed. Violent ebullition diminishes 
efficiency of this process as regards sedimentation and often carries 
out large quantities of finely divided solids. This is especially bad 
if the effluent is to be treated at once with chlorine.- The effluent fre- 
quently has an offensive odor, a great absorption power for dissolved 
oxygen and may contain substances inimical to oxidizing bacteria. 
Since it depends upon anaerobic bacterial action it should not be 
used preliminary to a method involving oxidation processes brought 
about by aerobic bacteria. 

Imhoff Tank. — The object here is to digest the sludge in chambers 
apart from the sewage in the sedimentation tank in order that the 
gases evolved will not mix with the clear liquid at the top. There are 
two chambers: a sedimentation chamber (upper chamber) and a sludge 
digestion chamber (lower chamber). The function of the upper part 
is to remove the settling solids. The sewage is passed through as 




SEWAGE 433 

quickly as possible, avoiding the exhaustion of the supply of oxygen. 
The action in the sludge chamber is similar to that of the septic tank. 
The solids accumulate in this chamber continuously and are digested 
by the bacteria. The gases pass out through openings or ventilators 
at the top of lower tank. 

Results Accomplished. — Practical detention period is about four 
hours. This permits a subsidence of 50 to 60 per cent, of the total 
suspended matter. 

Contact Filters or Biological Filters. — The failure of various tank 
treatments to remove fine suspended matter and the necessity of 
oxidizing organic matter of tank effluents before their discharge into 
natural waters led to the development of processes for transforming 
this organic matter into stable substances. The first of these was 
the contact or bacteria bed. This is a tank filled with broken stone, 
cinders, coke or other inert material. The material is about \ inch 
to 2 inches in size and the depth of the bed is about 6 feet. The 
voids in the bed, originally 40 to 50 per cent., gradually become 
filled with solid material and the contact material has to be removed 
and cleared after about five years' service. Bed with 20 per cent, 
voids will have far less capacity than one with 40 per cent. They are 
built in series of two or three. The effluent passes from one bed 
to another, being improved in quality by each successive treatment. 
Contact beds are filled with sewage, allowed to stand full, emptied and 
allowed to rest. 

The following schedule illustrates such a cycle: 
Rate of filling, 2 hours. However this is not so important. 
Contact period, 2 hours. 
Rate of emptying, \\ to 2 hours. 
Time of resting, 2 hours. 

Normal results are not obtained when beds are new. Rapid drain- 
ing tends to retard the formation of film. 

The work accomplished by the contact bed is dependent upon two 
main forces, physical and biological. It removes by surface attraction 
and absorption colloidal and dissolved substances which are later 
oxidized by bacterial action into stable inorganic compounds. The 
oxidizing power of the bed is dependent upon the supply of atmospheric 
oxygen absorbed during the rest periods. At intervals the biochemical 
activities need regeneration by obtaining oxygen from atmosphere 
or from nitrates. 

Results Accomplished. — General evidence shows that contact beds 
will give a non-putrescible effluent when they treat from 125,000 to 
150,000 gallons per acre per day for each foot of depth of effective 
filling material. Standard practice is a rate of 600,000 gallons per day 
for beds with an effective depth of 4 or 5 feet. Removes an average 
of 60 per cent, of applied bacteria, and 00 to 80 per cent, organic 
matter. 

Sprinkling Filters (known as trickling filters, percolating filters, etc.) . 
— These were developed from the contact filter, with the object of 
attaining higher rates of filtration and to eliminate serious complica- 
28 



434 SEWAGE AND WASTE DISPOSAL 

tions from clogging but are less expensive in some cases than contact 
filters. Filtering material is of broken stone, size 1 inch or 2 inches 
diameter; usual depth of bed, 5 to 7 feet. Bottom of bed is water- 
tight and has an underdrain system which collects effluent. Sewage 
is applied to beds in fine spray by means of fixed sprinkler nozzles 
whereby sewage is saturated with atmospheric oxygen. 

Method of Operation. — Sewage after treatment, such as settling in 
tank usually applied intermittently, a dosing period and a resting 
period. Dosing is regulated by a tank of fixed capacity which gives 
the nozzles an operating period of from two to five minutes. The 
resting period depends upon the rate of filtration, and is usually 
such that when the filter is operated at maximum rate it is about 
three times the dosing period. Resting is a disadvantage during 
the cold season. 

Results Accomplished. — A sprinkling filter can satisfactorily treat 
sewage at a rate of 2,000,000 gallons per acre per day. A disadvantage 
of this type of filter is that it discharges suspended solid matter, which 
must be settled by allowing effluent from the filter to be retained for a 
short period in sedimentation tanks. Even with this, better results 
for cheaper cost can be attained than with any method thus far 
developed. Experience shows that 80 to 90 per cent, of the bacteria 
can be removed. 

Intermittent Sand Filtration. — This method is generally used without 
preliminary treatment other than coarse screens or grit chambers. 
It consists of applying small volumes of sewage to areas of porous sand, 
allowing the sewage to drain from the pores of the bed, then fill with 
air, and in repeating the dose some hours or a day later. It affects 
a higher degree of purification than can be obtained by any other 
method in use. The effluent from it is stable and is free from turbidity 
and color. It removes about 99 per cent, of the bacteria present in 
the raw-sewage. 

The filtering material is sand, either fine grained or coarse. The 
rate of application for raw sewage will average 60,000 gallons per acre 
per day; the usual depth of the filtering material is from 4 to 6 feet. 
When there has been preliminary treatment the rate can be increased. 

Intermittency . — Intermittent dosage is essential as continuous 
filtration would allow no time for oxidation to proceed. The cycle 
should be regulated so that there is always sufficient oxygen present 
in the pores of the material and that the oxidizing processes are not 
discontinued and the anaerobic process allowed to begin. (See Report 
of Massachusetts State Board of Health, 1908.) 

Activated Sludge. — This process consists of aeration of sewage in 
tanks in contact with sludge from previously aerated sewage. The 
object of aeration is: 

1. To supply sufficient oxygen to support the aerobic action of 
bacteria. 

2. To produce sufficient agitation of the tank contents to assure 
intimate contact of the activated sludge particles with all of the 



SEWAGE 435 

sewage. The time required for aeration increases with the strength of 
the sewage and the degree of purification required. In practice it seems 
to be better to apply air at a constant rate and vary the period of aera- 
tion rather than to attempt to regulate the air discharge to meet the 
needs of the sewage at the moment. Four or five hours' aeration with 
20 per cent, sludge has given sufficient purification at Milwaukee, Wis. 
Approximately 2 cubic feet of air per gallon of sewage is required. 
Twenty to 40 per cent, of activated sludge is considered adequate. 
There is intimate relationship between the period of aeration, the 
quantity of air required and the proportion of activated sludge. This 
is accomplished by continuous aeration of activated sludge until 
nitrification is complete. It is in this condition that sludge is most 
active. The degree of purification effected by this method is dependent 
upon the maintenance of the activity of the nitrifying organisms. 
The activated sludge treatment appears to accomplish work com- 
parable with an efficient intermittent sand filter. This process is still 
in an experimental stage, but has many points of promise, particularly 
a possible commercial value to the sludge. 

Sterilization of Sewage. — This treatment is for the purpose of de- 
stroying objectionable bacteria, particularly germs of intestinal disease. 

Two methods of chlorination : 

1. Hypochlorite of lime. 

2. Liquid chlorine. 

The most satisfactory results have been obtained by the application 
of liquid chlorine to sewage, which has superseded the use of hypo- 
chlorites, as was brought out in the discussion in the chapter on Water 
Supply. 

Required doses: 

Crude sewage, 4 to 12 parts per 1,000,000 of chlorine. 
Septic effluent, 10 to 15 parts per 1,000,000 of chlorine. 
Sprinkling filter, 3 to 4 parts per 1,000,000 of chlorine. 

The required dose depends upon the amount of unstable organic 
matter present in the liquid to be treated. 

Efficiency. — The dose stated should remove 95 to 99 per cent, of the 
bacteria present. The time of contact has an influence in the efficiency 
of the process. In practice this is usually about thirty minutes. 

Sewage Irrigation. — In this process sewage is applied intermittently 
to land at a rate so low that it does not interfere with the raising and 
harvesting of crops. Rate varies from 3000 to 12,000 gallons per acre 
per day. Objections to its use relate to odors, prejudice to use of 
sewage in growing of vegetables, also to transmitting of disease germs 
by flies and other insects. 

Sludge Disposal. — Accompanying all sedimentation processes there 
is always the attendant necessity for disposal of sludge. This is a 
bothersome problem on account of two main reasons: 

1. The unstable nature of the material. 

2. The expense due to the large percentage of water in sludge (85 to 
98 per cent.) . 



430 SEWAGE AND WASTE DISPOSAL 

Sludge has a limited commercial utilization on account of its fertilizing 
properties, also on account of the grease that may be extracted from it. 
Methods of disposal: 

1. Digestion, then air drying. 

2. Sludge pressing, usually confined to chemical precipitation plants. 

3. Application to land. 

4. Dispersion into water (large cities with harbors). 
Conclusion. — Sewage purification is effected in successive steps, the 

degree being dependent upon the conditions to be satisfied. Examples 
of a method to be followed to secure an effluent that is thoroughly stable 
and will not cause putrefaction would involve following : 

1. (a) Grit chamber for removal of sand. 

(6) Imhoff tank and sludge drying beds (tank to remove suspended 
matter and permit digestion of sludge so that it can be dried on beds 
without causing nuisance). 

(c) Sprinkling filters — for oxidation of organic matter in solution, 
with accompanying basins for sedimenting the filter effluent. 

2. (a) Removal of suspended matter with fine screens. 
(b) Intermittent sand filtration. 

3. Final stage is disinfection or sterilization. 

The essentials of any process are securing the best results with least 
cost. Since the carrying out of the above processes is largely chemical 
and biological in its nature it is essential that the operation of all 
disposal plants be under the direction of someone thoroughly under- 
standing the processes involved. It is often found that sewage 
treatment plants fail on account of poor operation of the plant. 

WASTE DISPOSAL. 

Municipal Waste Disposal. — Very often when the word garbage 
is mentioned it brings to mind all kinds of refuse, instead of merely 
the waste from food. Garbage represents the kitchen waste including 
the refuse from the table as well as spoiled and unused food which is 
thrown away. 

In technical terms, rubbish includes paper, loose material accumu- 
lated during construction work, empty cans, broken glassware, etc. 

Street sweepings consist of horse droppings, dust, paper and miscel- 
laneous refuse material found on street pavements. 

Collection and Disposal of Refuse. — The amount of garbage per capita 
for a city averages 194 pounds, while rubbish amounts to 1250 to 1500 
pounds per capita per month. In cities where natural gas is used, 
rubbish would be much greater." During the past year or two the high 
prices paid for iron, paper, leather, etc., all tend to decrease the amount 
of rubbish. The largest item in refuse consists of ashes. It costs more 
for the collection of ashes than for other materials but it gives the least 
trouble for disposal. 

In the collection of refuse there are a number of schemes that have 
been employed, such as patented wagons with covered tops, motor 



WASTE DISPOSAL 437 

trucks, etc., and all have their special advantages. For instance in 
large cities where houses are close together, horse drawn wagons are 
advantageous while for small cities motor trucks are much more 
economical. In some places a method has been installed which con- 
sists of collecting covered cans and at the same time leaving a clean one 
in its place. When this is carefully done it gives satisfaction. 

The method of collecting depends upon the kind of disposal that is 
to be installed. For instance if garbage is wrapped in paper, collected 
twice a week in summer and once a week in winter, the additional cost 
does not exceed 25 per cent, for collection and disposal. Wrapped 
garbage is all right for incinerators but not advantageous for dumping. 
For this reason it is necessary to study the collecting system in a city 
as well as the system for disposal of garbage. 

The separation of garbage from other waste is more necessary than 
other classes of refuse because of the putrescibility of garbage ; heat and 
cold affects it, uncovered garbage brings flies, and eggs are sometimes 
deposited in it. 

Disposal of Waste.— The disposal of waste is being taken care of by 
dumping, burning, reduction, incineration and separation of garbage 
for feeding purposes. 

The process of dumping as commonly practised is to be condemned. 
There are times when such a method may be used but the material 
should be placed in furrows rather than on one main dump, and as 
much of the combustible rubbish deposited among the wet garbage as 
possible in order to serve as fuel for burning. Strict attention should 
be given to see that all material is burned and afterward the ground 
be sprinkled with oil to prevent any fly-breeding from unburned 
material. There is much trouble caused from the smoke and fumes, 
which are offensive, from the burning material ; also papers blow about 
and make the place very uninviting. 

The burying of garbage and refuse is very seldom practised, as it 
takes quite a large space of ground and the results are not very satis- 
factory, at the same time being a very great waste of material. 

The process of reduction is practised in Los Angeles, Cal., New 
Bedford, Mass., New York City and elsewhere. Much trouble was 
found from gases and fumes at first but a new process has been devised 
which takes care of this and diminishes the nuisance. Garbage is placed 
in a closed tank, sealed with jacketed w^alls and bottom containing steam 
and a device in the center to keep the garbage stirred all the time. 
Garbage, which contains 75 per cent, of water, is evaporated by the 
heat of the steam. Later solvents are added in order to dissolve 
the grease. Later the grease is obtained by the evaporation of the 
solvents, which are used over again in the extraction work. For large 
communities a garbage reduction process is quite advantageous. There 
is an increasing demand for waste products from garbage for the 
manufacture of fertilizer. The grease that is recovered splits up into 
various by-products; glycerin being the most valuable. 

The process of incineration consists of burning everything — garbage, 



438 SEWAGE AND WASTE DISPOSAL 

refuse and all waste material except metals and glassware. This is 
carried out through high temperature destructives, the heat from which 
is used for power to obtain city light. 

Feeding of Swine.— Each 1000 of population produces food waste 
sufficient to fit 25 hogs for market. At the present price, a ton of 
garbage produces seven to eight dollars worth of pork. 

From many considerations, garbage might well be termed a war time 
discovery, brought about through high prices, the shortage of food and 
the patriotic response to the need of war time conservation. 

The housewife evidently decided to solve the garbage problem by 
eliminating garbage. She unquestionably cut down materially not 
only the volume of her kitchen and table refuse but even further 
reduced its meat and fat contents. 

Figures Obtained from Statistical Division of United States Food 
Administration. — The following are figures obtained from a survey of 
96 cities with an estimated population of 26,000,000, reporting regularly 
each month for two years. 

There was 10 per cent, less garbage collected in 1917 and 1918 than 
in the previous year, which shows a genuine conservation of food by the 
urban population. 

In regard to the grease recovery from garbage, only a comparatively 
few States had reduction plants. However, twelve cities showed a 
reduction of 30 per cent, of gross grease recovered from garbage in 1917 
and 1918 as compared with 1916. The average per cent, of grease in 
garbage dropped from 2.15 to 1.85. The 1918 grease content of gar- 
bage in richness averaged 18 per cent, less than 1917. Compared with 
1916 it showed a reduction of 25 per cent. The total volume of gar- 
bage grease recovered showed a reduction of 28 per cent, from the 1917 
recoveries and the 1917 recoveries exceed those of 1916 by 13 per cent. 

It is estimated that the amount of garbage still wasted is sufficient 
to produce more than 30,000,000 pounds of garbage grease, 60,000 tons 
of fertilizer tankage and 40,000,000 pounds of pork. 

The conservation of food and garbage during the w T ar has had its 
effect upon the different cities over the country. Syracuse and New 
Orleans have had garbage reduction plants authorized. San Francisco 
opened bids contemplating utilization in January, 1917. Wheeling, 
W. Va., entered into a contract for disposal by feeding. Norfolk, Va., 
and Newark, N. J., are considering a number of propositions sub- 
mitted to them by various corporations. The amount of garbage still 
available for utilization is enormous. 

Disposal of Manure. — This is a very important matter whether or not 
it has reference to the prevention of fly-breeding around a dwelling 
house, camp or barracks. 

It is commonly known that the house fly, Musca domestica, con- 
stitutes more than 98 per cent, of the flies found in dining halls and 
dwellings, and also that the eggs of the house fly are usually laid in 
horse manure, which shows the necessity of properly disposing of this 
material. 



DISPOSAL 6f WASTE IN ARMY CANTOXMKNTS 430 



LIFE HISTORY OF THE HOUSE FLY. 

The eggs are usually laid upon horse manure, although they breed 
in human excrement or decaying vegetables. One adult female lays 
about 120 eggs at a time and may lay between two and four batches 
during her life. Eggs hatch in from eight to twenty-four hours, and 
the larvse, or maggots, issuing from them are very small and trans- 
parent. They obtain their full growth in four to five days, when the 
maggots appear creamy white in color. Just before pupation, the 
dormant state, the maggots migrate to the cooler, dry edges of the 
pile, burrowing into the solid or even crawling several feet from the 
pile in search of a cool spot. The pupae stage lasts from three to ten 
days. They are barrel-shaped and dark brown in color. At the end 
of cubation the adult fly emerges, the wings spread and the cycle is 
complete, taking eight days from the time of deposition of eggs to the 
emergence of the adult fly. The female adult is ready to deposit eggs 
in three or four days in midsummer. 

Thus to check the fly nuisance one can readily see that the immediate 
removal of manure or soil bedding from the corral or stable is most 
essential. 

The manure may be disposed of by being taken away every morning 
and spread out thinly so that it will dry. Or it may be placed into 
fly-proof bins and held there for several days until it is hauled away. 

Manure may be sprayed with hellebore, borax and acid phosphate 
in order to kill the maggots, and at the same time preserve the fertil- 
izing value; but these methods are too expensive to consider when 
large quantities of manure are to be treated. A more practical method 
of disposal, and one in which it can be used as a fertilizer, is the building 
of the manure in compact heaps. A firm ground should be selected 
for this purpose, in order to check the boring of maggots. It is also 
useful to sprinkle ordinary road oil on the area where the manure is 
to be packed. In addition to compacting the sides of the pile it may 
be necessary to sift some powdered borax over them whenever maggots 
are seen. 



DISPOSAL OF WASTE IN U. S. ARMY CANTONMENTS. 

After much discussion in regard to the manner of waste disposal by 
the National Army and National Guard Camps it was decided to sell 
the material by contract rather than for the Government to install 
incinerators or reduction plants. The material was sold on the number 
of occupants per month of each camp. The prices received varied 
at the different camps, ranging from 3 to 9 cents per month per man, 
making an average of 5 cents. This covered all waste material, with 
the exception of manure. As stated the basis of sale was different at 
some of the camps; for instance, at Camp Travers, San Antonio, the 
following prices prevailed: Bones $11.00, garbage $1.90 and waste- 
paper $4.00 per ton, while at Camp Devens, Mass., the contractor paid 



440 SEWAGE AND WASTE DISPOSAL 

$2160 a month for all waste, including the moving of material but not 
the collection. 

Collection of Material. — At eaeh army kitchen were placed a number 
of different garbage cans with tight covers, where the material was 
sorted. Tin cans being placed in one, garbage in another, paper in 
another, etc. The cans were collected by the Government trucks and 
taken to what is known as a transfer station. The transfer station 
consisted of a building with a covered loading platform and a device 
for washing cans. Boilers were installed in order to have hot water 
for this purpose and in some instances a small incinerator was installed 
for the burning of rubbish. The Government trucks unload the cans 
from one side of the platform and the contractor hauled away the cans 
from the opposite side. Clean and thoroughly washed garbage cans 
were returned to the army kitchens. The contractor was not per- 
mitted to keep the garbage within three miles of the camp in order that 
there be no chance of fly-breeding by the establishment of piggeries 
nearby. 

The disposal of manure was quite a problem, as it is estimated that 
there were 1200 horses at each camp, which would produce about 120 
tons of manure per day. For the Government to attempt to dispose 
of the manure it would cost 60 cents per ton to haul and to incinerate; 
therefore the Government, by selling the manure, was able to make a 
net return of $200,000, or approximately $2,000,000 per year, plus 
saving the cost of construction of an incinerator and the cost of burning 
other material than manure, which would have added at least $120,000 
more. 

Dish water and slop water from kitchens were evaporated upon small 
incinerators constructed by individual companies. Originally these 
incinerators attempted to take care of the disposal of the garbage, 
but this was never thoroughly done. 

Different types of incinerators have been recommended for use in 
semipermanent or permanent camps to dispose of sewage water, as 
well as being adapted for incineration of garbage, etc. 

Palmer Incinerator. — The following is a description of the "Palmer" 
incinerator, designed by Capt. George T. Palmer, Sanitary Corps, after 
his experience in the use of a number of different types of incinerators. 
This type of incinerator was used at several of the embarkation camps 
with excellent results. 

Dimensions. — The incinerator is constructed with brick walls, 
measures 1 1 feet by 3 feet 4 inches in plan and is 4 feet 4 inches at its 
greatest height. The evaporating and incinerating devices are entirely 
supported by pipes set in the walls. The incinerator is built to accom- 
modate 4 foot cord wood as fuel. 

Evaporation. — The tanks (A) have a capacity of 10 to 15 gallons 
and are filled by an attendant from a 33 gallon galvanized iron col- 
lection can into which the kitchen water and liquids from mess kits 
have been poured through a box screen to remove the coarser solids. 
Three or more i-inch holes fitted with wooden plugs near the bottom 



DISPOSAL OF WASTE IN ARMY CANTOXMEXTS 



441 



of the can permit the flow of liquids from tank (A) to be and to run out 
onto the perforated trough, which is formed from the upper part of the 
inclined evaporating sheet ( B) . The perforations in this trough should 
be about § inch in diameter to prevent frequent clogging and should 
be spaced from 4 inches to 6 inches apart. 




1 



Si 




-n 



| S >^ 



mm 




J_-_" 



Falling through the perforations the water flows down the brick 
steps ( H) which form the bottom of the flue. Evaporation takes place 
here very effectively as the water is rapidly raised in temperature and 
exposed to moving heated air. The water passes off as a vapor with the 
flue gases. 



442 Sl<\\ AGK AM) WASTE DISPOSAL 

Sonic of the existing liquids from tank (A) which will not. readily 
flow through the perforations in the trough will flow down the evapor- 
ating sheet (B), and the excess flows into pan (C) where it is evapo- 
rated. Any water which is not evaporated on the brick steps ( H) will 
flow into the trough (J) and remain there until evaporated by the 
flue gases. If this trough overflows, it will be readily known by the 
hissing noise in the fire box ( 67) . 

There is no difficulty in evaporating at least 150 gallons of liquid 
per day in this manner, and with careful attention and a hot fire the 
amount can readily be exceeded. About one-tw r elfth of a cord of wood 
is required per day. 

Garbage Incineration. — The grate {D) is made up of 1-inch pipe 
laid on the heating coil (E) which in turn is supported by three or 
more pipes set into the brick walls. There should be a sufficient 
number of pipes about 5 feet long in the grate to allow not more than a 
1-inch space between them. Garbage is placed on the grate from above 
by removing one or more of the iron plates (L). When the garbage 
is sufficiently dried the pipes may be spread apart by hand, thus allow- 
ing the dried garbage to fall into the fire and be burned. 

The screenings from the sullage water and coffee grounds may also 
be disposed of on the grate. 

Burning Out of Tin Cans. — The r grate (D) may also be used for 
burning out tin cans, as they will be subjected to sufficient heat to 
incinerate any food material left in them. It is easier to add and to 
remove cans from this grate than from the main fire pit (G) . 

Heating Water. — The heating coil (E) is a single circuit of 1-inch 
pipe, w T hich is attached to a barrel on the side of the incinerator. The 
upper or return pipe should enter the barrel about 1 or If feet from the 
top, whereas the lower or feed pipe leaves the barrel from 6 to 12 inches 
from the bottom. The barrel is placed on a stand lj feet above the 
ground. A tap placed about lj or 2 feet from the bottom of the barrel 
provides a convenient means for drawing hot water. 

Attendance. — For efficient operation this incinerator needs the time 
and attention of but one man. Intelligence in the feeding of liquids 
and garbage and in the care of the fire will, to a large measure, deter- 
mine the capacity of the incinerator. 

Necessary Fuel. — Generally speaking this type of incinerator requires 
one pound of fuel to burn 5 J pounds of garbage. This is in contrast 
to other types which require 1 pound of fuel to burn 1 pound of 
garbage. 

REFERENCES. 

1. Standard Methods for the Examination of Water and Sewage. 

2. Scientific Publications, Wallace & Tiernan Co., Inc. 

3. Metcalf & Eddy: American Sewerage Practice, Vol. III. 

4. Fuller, George W. ; Sewage Disposal. 

5. Phelps, Prof. E. B.: Self-purification of Streams. 

6. Rideal, Samuel: Sewage. 



CHAPTER XVII. 

HOUSING AND PLUMBING. 

By ARTHUR R. GUERARD, M.D. 

HOUSING. 

The importance of observing the principles of hygiene in the con- 
struction of habitations for human beings is not sufficiently appreciated 
by the public. Architects and builders themselves have not kept pace 
with the sanitarian in the study of the conditions necessary to be 
observed in building a dwelling house which shall answer the require- 
ments of sanitary science. 

Inseparable from the question of the defective construction of 
dwellings is that of overcrowding and lack of proper ventilation, light, 
etc. The concentration of population in cities, resulting from the 
progress of modern industrialism has given rise to serious evils in con- 
nection with the housing of the poor. Scarcity of accommodations, 
coupled with high rents has resulted in a degree of overcrowding, and 
an exploitation of cheap and obsolete dwellings that threaten the 
physical and moral health of the working class. 

The housing problem presents various aspects according to local 
conditions. In our large cities, especially in New York, its chief factor 
consists in undue aggregation of population upon a limited area of 
ground, with the resultant tendency to occupy as much of the building 
space as possible with lofty structures, thus depriving the tenants of 
adequate light and air. In European cities, on the other hand, where 
building operations have been less active, the evil is manifested in the 
form of occupancy by several persons of apartments designed for one, 
with consequent menace to health. The vital importance of the appli- 
cation of sanitary laws in the construction and occupancy of dwellings 
cannot be overestimated. 

The housing problem at present most prominent in the public mind 
concerns overcrowding in the great cities, being coextensive with 
modern industry. Investigations carried on in New York, Chicago, 
London, Paris, Berlin and Stockholm tell the same story of a working 
population, overcrowded in houses and tenements, with resultant 
weakening of health, prevalence of infectious diseases and moral decay. 
In the United States the problem first assumed acute form in New 
York City. Agitation for public control of housing in New York began 
in 1842, but no action was taken until 1864, when a council of hygiene 
and public health was organized. In 1867 the first law on the subject 
of tenements was enacted. Its provisions, however, were entirely 
inadequate, and builders were practically free to follow their own 



I 1 I HOUSING AND PLUMBING 

devices until the law of 1901 was enacted. This law, improved by 
successive amendments and efficiently enforced has done much toward 
improving housing conditions in New York. But it lias been impossible, 
apparently, to overcome all the worst consequences of the earlier 
period of license in construction. As late as 1900 there were in New 
York City 1000 "dumb-bell" tenements, 20,000 houses in which most 
of the rooms were dark, 100,000 rooms without windows, and 1,000,000 
persons without facilities for baths in their houses. None the less. 
the condition of the tenements has been notably improved. To this 
improvement must, in part, be credited the decline in the death-rate 
from 20 per thousand in 1900 to less than 12 per thousand in 1920. 

The regulation of housing in other cities received a great impetus 
from the New York law of 1901. In 1904, a similar law was enacted 
in Xew Jersey, and by 1912 such laws had been enacted in six other 
States, applying for the most part only to large cities. In 1913, 82 
cities in the United States and 5 in Canada had housing regulations in 
force. 

The housing regulations include, as a rule, restrictions upon the 
percentage of lot area that may be covered by a building; requirements 
as to cubic content of each room intended for occupation and as to 
light and air; regulations as to plumbing; provision of safeguards 
against fire, such as specifications of fireproof or slow-burning materials 
for buildings above a given height, non-combustible stairways, fire 
escapes, etc. Such regulations should be enforced through the regular 
police, through the local board of health, or through a special adminis- 
trative organization like the Tenement House Commission of New York, 
the last method being essential to effectiveness. 

In the case of buildings in existence at the time of the enactment 
of housing laws it is possible to make only limited improvements. On 
the grounds of public safety and health an energetic administrative 
board can impose certain improvements, such as the provision of fire 
escapes, the cutting of windows in dark rooms, and the installation of 
proper plumbing. The serious evils of overbuilding in respect of area 
lot and of improper construction cannot thus be reached. 

The problem of housing the masses, particularly in larger cities, is 
too vast a subject to be dealt with fully in a work of this kind; but the 
fearful prevalence of tuberculosis in many of the tenement house dis- 
tricts of our great cities demands special notice. The often described 
"lung block" of New York, on Cherry and Market Streets, had in 
1894-5 a death-rate from tuberculosis of 37.5 per cent., while the 
death-rate in the city at large w r as only 21.5 per cent. For the ten years 
1894 to 1904 no less than 291 cases of tuberculosis were reported to 
the Department of Health from this block, yet in spite of this and 
repeated complaints of violation of the Tenement House Law, a long 
time elapsed before the lung block was finally destroyed and the space 
partly converted into a playground. Every collection of dark, unclean, 
unventilated tenements is a lung block, dealing death to those, who 
from economic reasons, not from choice, must live there. 



HOUSING 445 

Viewed from a purely utilitarian standpoint, money invested by 
philanthropic citizens in model tenement houses gives to the investor, 
as a rule, as high and higher percentage than he is apt to receive from 
other safe investments. There are several such enterprises* in this 
country, involving both philanthropic and business principles, which 
pay the investors from 5 to 6 per cent. In New York there are the 
A. T. White Improved Dwelling Company of Brooklyn, who erected 
the Home Tower and Riverside Buildings; the Astral apartments of 
Pratt Institute; the Improved Dwelling Association, with model tene- 
ments at 71st Street; and the Tenement House Building Company, 
with property in Cherry Street. In Boston are the Harrison Avenue 
Estate, the Rufus Mills Memorial Building, Cooperative Building 
Company, and the Improved Dwelling Association. In Philadelphia 
is the Theodore Starr Property. The City and Suburban Company 
of New York City was organized in 1896 as the outcome of the 
Improved Housing Conference. It aims to offer a safe investment 
returning 5 per cent, and to provide the best accommodations for work- 
ing people. Under this head the most striking development is the 
"Garden City Movement" which seeks to solve the housing problem 
by removing city workers to suburban areas. This plan has been tried 
with some success both in Europe and America. An example of the 
movement in this country is the community established at Forest 
Hills, L. I., by the Russell Sage Foundation. 

But important as philanthropic efforts at housing reform really aie, 
it is easy to exaggerate their influence upon the general housing situa- 
tion. According to estimates of Yeiller, in the years 1862-1901, 25 
groups of tenements, accommodating 3588 families were erected in 
New York under philanthropic auspices; 27,100 tenemen'ts, accom- 
modating 253,510 families w T ere erected by speculative builders. In 
the years 1902-1908 the philanthropic enterprises provided accommo- 
dations for 1871 families, while speculative enterprise provided for 
253,255 families. It is thus evident that even a slight improvement, 
imposed by public authority upon the mass of speculative builders 
may contribute more to the solution of the general housing problem 
than the aggregate of philanthropic endeavor. Health officers and 
sanitarians should concentrate their efforts upon improving the hous- 
ing regulations and securing their efficient administration. 

Type of Dwelling. — The general types of dwellings concerned in 
the housing problems are: (1) One-family dwellings; (2) two-family 
dwellings; (3) tenements. The promotion of the one-family dwelling is 
one of the main objects of housing reform — detached houses, each 
with its own plot of ground — such as have been developed in various 
cities with considerable success. Two-family dwellings may also be 
quite satisfactory under certain conditions. This class of house may 
be arranged either as a double house with a party wall between and 
separate entrances on each side, and each family occupying one-half 
the house ; or as a single house in which one family occupies the ground 
floor and basement, and a second family occupies the second and third 



440 HOUSING AND PLUMBING 

floors, with separate entrances for each family. The tenement house 
is one in which more than two families dwell independently, but shar- 
ing common hallways (though there are various definitions under 
different local laws). It is against this class of dwellings that most of 
the housing reform has been directed, as above indicated. 

Essential Requirements of a Healthful Private Dwelling. — In order 
to be healthful a dwelling should fulfill the following require- 
ments : 

1. It should be dry and free from dampness, be well drained, and 
have the ground air excluded from it. 

2. It should be well sewered, so that all liquid waste matters are 
nowhere stagnating, but are immediately and completely removed. 

3. It should have a sanitary system of plumbing, pipes, fixtures and 
fittings. 

4. It should be well lighted, and have as much sun exposure as 
possible. 

5. It should have an ample supply of pure water, flowing under a 
good pressure and protected in the house from all possible sources of 
contamination. 

6. It should be properly ventilated, and be supplied with pure air 
in all parts. 

7. It should be kept clean and free from any nuisances. 

8. It should have healthful surroundings. 

Location and Site. — The site of the dwelling should be dry. It should 
be protected, if possible, against violent winds, although a free circula- 
tion of air all around the house should be secured. Close proximity to 
cemeteries^ marshes and injurious manufacturing establishments or 
industries must be avoided. A requisite of the greatest importance is 
the ability to command an abundant supply of pure water for drinking 
and other purposes. 

Soil. — The soil should be porous and free from decomposing animal or 
vegetable matter or excreta of man or animals. It should be freely 
permeable to air and water; the highest level of the ground water 
should be nine or ten feet of the surface, and the fluctuation of the 
ground water should be limited. It is impossible to say positively that 
any kind of soil is healthy or unhealthy, merely from a knowledge of 
its geological character, as the accidental modifying conditions such 
as organic impurities, moisture, the level and fluctuations of the ground 
water are of much greater importance than the geological formation 
of the soil. But as a rule, sites on granite, metamorphic and trap rocks, 
clay, slate, sandstone, sand and gravel are usually healthy. Limestone, 
clay, dense marls and alluvial soils generally are to be regarded with 
suspicion. Cultivated soils are often healthy, nor has it been proved 
that the use of manure is necessarily hurtful. 

Where wet, impermeable or impure soil must, of necessity, be chosen 
as a building site, it should be thoroughly drained. The minimum 
depth at which drains are laid should be not less than four feet below 
the floor of the cellar or basement. Such soil should be covered with a 






HOUSING 447 

thick layer of asphalt-cement under the house in order to prevent the 
aspiration of the polluted ground air into the building. 

It is a common custom in cities to fill in irregularities of the building- 
site with street sweepings and garbage, which always contain large 
qualities of decomposing organic matter. This is a violation of the 
principles of hygiene. It is undesirable to use such decaying or putre- 
fying organic material for the purpose of grading streets in cities and 
towns. It should be the constant endeavor of all health officers to 
prevent the pollution of the soil as much as possible in towns and 
villages. The separation of the garbage from the ashes yields a suitable 
material. 

Where houses are built on the declivity of a hill, the upper wall 
should not be built directly against the ground, as it would tend to 
keep the wall damp. A vacant space should be left between the wall 
and the ground to permit free access of air and light. 

As regards trees in country sites, it may be said that, while it is true 
that they give shade in summer against the sun, and shelter in winter 
against raw winds, they must not stand too near a dwelling. If so, they 
darken the rooms, prevent the entrance of sunlight, deprive the house 
of proper currents of air and promote dampness of the walls. 

Building Material. — The nature of the most suitable building depends 
upon so many varying circumstances that no definite rules can be laid 
down. Generally speaking, however, moderately hard burned brick 
is the most serviceable and available. It is easily permeable by the 
air, and so permits natural ventilation through the walls, unless this is 
prevented by other means. It does not absorb and hold water readily; 
hence damp walls are infrequent if brick is used. It is probably the 
most durable of all building material. On account of its porosity a 
brick wall is a poor conductor of heat. It therefore prevents rapid 
cooling of a room in cold weather, and likewise retards the heating of 
the inside air from without in summer. Another very great advantage 
is its resistance to a very high degree of heat, brick being perhaps more 
nearly fireproof than any other building material. 

Next to brick, granite, marble and sandstone are the most service- 
able building materials. Very porous sandstone is, however, not very 
durable in cold climates, as the stone absorbs large quantities of water, 
which, in consequence of the expansion due to freezing, produces a 
gradual but progressive disintegration. 

In hot climates light wooden buildings are advantageous, because 
they cool off very rapidly after the sun has disappeared. On account 
of the numerous joints and fissures in a frame building, natural ven- 
tilation goes on very steadily and to a considerable extent. 

The application of paint to the walls, either within or without, 
checks the transpiration of air through the walls, thus limiting natural 
ventilation. Calcimining, on the other hand, offers very little obstruc- 
tion to the passage of air. Wall paper is about midway between paint 
and lime-coating in its obstructive effect. 

Newly built houses should not be occupied until the walls have 



448 HOUSING AND PLUMBING 

become dry. Moisture in the walls is probably a not infrequent source 
of ill health; it offers favorable conditions for the development of dis- 
ease germs, and, by filling up the pores of the material of which the 
walls are composed, prevents the free transpiration of atmospheric air 
through them. 

Moisture of the walls is sometimes due to ascent of the water from 
the soil by capillary attraction. This may be prevented by interposing 
an impervious layer of slate, etc., in the foundation wall. 

Arrangement and Size of Rooms ; Ventilation and Heating Arrangements. 
— If possible, attention should be given in grouping the rooms of a 
house to the question of aspect or outlook. Living rooms should 
front toward the south or southeast; the principal bed-room may 
have an outlook toward the east or northeast, thus getting the morn- 
ing sun. A dining-room may look tow r ard the north, northeast, or 
northwest, while the domestic quarters will usually be located on the 
west or northwest side of the dwelling. 

A house in general should be so placed as to get the greatest amount 
of sunlight to the interior. All rooms should be airy, sunny and well 
lighted. Nothing is so detrimental to domestic cleanliness as darkness. 
Every room of the house should have large, outside windows, reaching 
well up to the ceiling. Roofs of wide porches or piazzas are delightful 
sheltering places in the country against the hot sun of summer, but 
they rob the lower rooms of much necessary light. Shutters and blinds 
are desirable in some places to keep out too much sun, but they must 
not be kept closed all day. 

The windows and doors should be screened during, at least, a part 
of the year, in order to prevent the entrance of flies, mosquitoes and 
other insects. Screens are particularly desirable for the bedroom of 
the house and also for the dining-room, the kitchen and the pantry. 
This is not only a question of convenience and comfort, but one of 
health. Both flies and mosquitoes are carriers of disease; the screening 
of houses is therefore to be considered as a sanitary measure of infinite 
importance. But besides the window and door screens to keep out these 
insects, it is necessary that more radical efforts should be made to 
destroy flies and mosquitoes where they breed. 

Flies breed mostly in manure. All the manure from horse stables 
should be treated with lime or kerosene and kept in securely closed pits, 
in country places, and frequently removed. Privy vaults and cesspools 
should be treated also. Dirt and accumulations of any kind around a 
house should be abolished, and in this way much can be done to 
mitigate the evil. The maintenance of absolute cleanliness inside of 
houses is of the greatest assistance. In cities the reduction in the 
number of horse stables and the increasing use of automobiles, motor 
cycles, and electric cars help verv materially in the fight against 
flies. 

In the same way, through the use of window and door screens, and 
of mosquito nettings over the beds is desirable, it is of much more 
importance to destroy the breeding places of mosquitoes. All cisterns, 



HOUSING 449 

rain-water barrels, water tanks and cesspools about the house should 
be well screened. All stagnant pools of water should, whenever pos- 
sible, be drained or filled in, or else these places may be treated with 
kerosene oil to destroy the larva?. In ponds and pools of clear water 
the introduction of small fish, which feed on the larva?, is recommended. 

As to the size of rooms in a dwelling, no room should be less than 
eight or nine feet in height. The sleeping room should be large; it 
should never contain less than 1000 cubic feet of air space for adults, 
and 750 cubic feet for children under ten years of age, and provision 
must be .made for changing this air sufficiently often to maintain it at 
its standard of purity. Details for accomplishing this will vary with 
the architect's design, the material of which the house is constructed, 
the climate, and the season. The principles laid down in the section on 
ventilation should be followed. 

In cold weather the air should be warmed, either before its entrance 
into the room or afterward, by some form of heating apparatus, fire- 
place, stove or furnace. The details of the heating apparatus are 
given elsewhere, and they may be left to individual taste or other 
circumstances. It may be noted, however, in passing, that the pre- 
vailing method of heating houses by means of hot air is objectionable 
for various reasons; partly because the air is too dry to be comfort- 
able; partly because organic matter is frequently present and gives to 
the air an offensive odor when the degree of heat is high enough to 
scorch the organic matter. Both of these objections are, however, 
removable if care is taken to supply artificially the necessary amount 
of moisture, and to have the furnace large enough so that the tem- 
perature need never be raised to a very high degree. Heating by hot 
water or steam obviates the latter objection, but not the former, and 
unless special provision is made to let fresh air into the room from 
outside, the inside air is reheated. Moreover, both hot water and steam 
heating methods necessitate a more expensive heating system. 

Some form of artificial light will also be needed in all dwellings. Cer- 
tain dangers are necessary accompaniments of all available methods 
of artificial illumination. The danger of fire is, of course, the most 
serious. This danger is probably least where candles are used, and 
greatest where the volatile oils (kerosene, gasoline) are employed. The 
use of candles is seldom resorted to at the present time except to give 
extra light temporarily, or for the decoration of the dining table. For 
general illumination the use of candles also results in pollution of the 
air by carbon dioxide and other products of combustion to a greater 
degree than when other illuminating agents are employed; they give 
out, too, a larger amount of heat in proportion to their illuminating 
power. Kerosene oil yields a good light when burned in a proper lamp, 
and is cheap, but the dangers from explosion and fire are considerable. 
The danger from explosion can be greatly reduced by always keeping 
the lamp filled nearly to the top and never filling it near a light or fire. 
The danger of explosion is increased when the chimney of the lamp 
is broken, as then the temperature of the metal collar, by which the 

29 



450 HOUSING AND PLUMBING 

burner is fastened to the lamp, is rapidly raised and the oil is vaporized, 
forming an explosive mixture of air and the vapor of the oil. 

The use of coal-gas is probably attended by less danger than the 
lighter oils, but by more than other means of illumination. In addition 
to the danger from fire and explosion, which are inevitable accompani- 
ments of defects in the fixtures, the escaping gas is itself very poisonous 
from the large amount of carbon monoxide it contains. That variety 
of illuminating gas known as "water-gas" is more dangerous to inhale 
than coal-gas owing to the greater amount of carbon monoxide in it. 
The "natural gas" used as a fuel and illuminant in some places in the 
United States is especially dangerous from the total absence of odor. 

The danger in the use of illuminating gas arises from two sources: 

(1) from unburned gas which escapes into the atmosphere through 
defective pipes or fixtures, or through burners accidentally open, and 

(2) from vitiation of the atmosphere through the products of burning 
gas. The National Board of Fire Underwriters has published a table 
of gas losses which shows that over 14 per cent, of the total product of 
gas plants leaks into the streets and houses of cities supplied. The 
danger to houses from escaping gas is much greater in the winter time, 
when the street surface is frozen, and when houses, on account of their 
higher temperature, act as chimneys to draw in the ground air, and with 
it the gas that has leaked into the soil. Gas thus escaping may follow 
water or sewer pipes and enter even those houses which have no gas 
connections. In order to remove the constant menace to life and 
property, through explosion and asphyxiation, which is afforded by 
leaky gas mains, the whole matter should be under the strictest sur- 
veillance and control by the public authorities. The introduction in 
our large cities by subways for underground pipes and wires would 
remedy the evil by rendering gas mains easily accessible for con- 
stant inspection. In this way the slightest leak would be detected, 
and the danger of deterioration of the main through rust and of their 
breaking through settling of the soil would also be removed. 

For cases of isolated lighting, as in country houses, etc., air gas, oil 
gas, and acetylene are chiefly used. Among these the oldest method 
is air gas, popularly known as "naphtha gas," which consists of air 
charged with naphtha or gasoline vapor. If the product is to be used 
exclusively for house lighting and heating, care must be taken that the 
mixture contains either less than 2 per cent, or more than 5 per cent, of 
the hydrocarbon vapor, as it is between these figures that the mixture is 
explosive and only fit for use in the gasoline engine. Where the mix- 
ture consists of more than 5 per cent, vapor, it must be mixed with air 
before combustion. Such mixtures are now used almost exclusively 
for heating purposes and are familiar in the painter's or brazier's torch 
and plumber's furnace. Either piece of apparatus consists of a strong 
brass cylinder provided with an air pump or heating coil and a burner 
tube filled with fibrous material, the outer end of which terminates in 
a needle valve for controlling the supply of heated gas, and an air- 
mjxing chamber. Of the few types of apparatus of this order still used 



HOUSING 451 

for house lighting, the simplest consist of a revolving air-drum driven 
by weight and capable of forcing warm house air through a pipe to an 
underground tank, situated some distance (50 feet) from the building. 
This pipe enters the top of the tank, bends at right angles, and continues 
nearly to the bottom. Another pipe for conveying the vapor-laden 
air leaves the top of the tank and returns to the building. A supply 
pipe for gasoline extends just above the ground line and is closed except 
when the tank requires filling. It is obvious that the house air, impelled 
by the drum, bubbles through the gasoline and becomes saturated 
with vapor. Special burners, filled with fiber provided with an air- 
mixing device, are necessary, and incandescent mantles are used to give 
a brighter light. Many forms of air-gas machines are now operated 
by gasoline-engine power, the exhaust from which heats the air used in 
the operation, thus obtaining more constant results. A simple form of 
apparatus of the pressure type is quite largely used in small household 
stoves and differs not materially from the plumber's furnace, except 
that the air pump is absent. 

Oil gas or illuminating mixtures made by the destructive distillation 
of oil or fats, antedates coal gas, but failed from high cost of the original 
material. With the production of cheap liquid hydrocarbons from 
various sources, the project revived and is now extensively employed 
for enriching water gas or to be sold in a compressed form for isolated 
lighting — railway cars, boats, buoys, country dwellings, and street 
lamps. This gas is best known as "Pintsch gas." 

Acetylene (C 2 H 2 ) is produced by adding water to calcium carbide 
or vice versa. The gas is pure, requiring no further treatment, and the 
operation of making may be stopped at will. As this gas is generated 
imder pressure, a strong well-made apparatus is necessary, and there 
is always the element of danger from excessive pressure. This form of 
lighting has been very popular, especially on a small scale, as in bicycle 
and automobile lamps, etc., and also for house illumination of isolated 
dwellings. Acetylene burns best in the Y-shaped burner. The aper- 
tures are in the inside of the Y arms near the top. The two opposing 
streams of gas impinging spread out in fan-shaped flame and yield a 
brilliant steady white light. Acetylene is less poisoning than any other 
illuminating gas, and if it escapes in any quantity may be recognized 
by its characteristic odor. There are numerous acetylene generators 
in the market; of the various types, those in which the carbide is fed 
into the water are considered the best. Some underwriters require the 
machine to be placed in a frostproof out-building, at some distance 
from the house ; others permit locating the generator in the basement or 
cellar. None should be used except one approved by the underwriters. 

The Edison incandescent electric light is probably open to less objec- 
tion on the score of danger than any other of the illuminating systems 
mentioned. There is no trustworthy evidence that the electric light 
has any unfavorable influence on the vision. The advantages of the 
electric light, besides the brilliant white light it gives, are that it is 
steady and does not produce any heat, nor does it pollute the air with 



452 HOUSING AND PLUMBING 

carbon dioxide and other products of combustion. Incandescent lamps 
are usually designated as carbon, metallized carbon, tantalum, or 
tungsten lamps, according to the nature of their filaments. With the 
general adoption of tungsten metal as a filament material, the use of 
carbon filaments has very greatly declined. In some tungsten lamps 
of recent development a radical departure is made from all previous 
practice by filling the bulb with nitrogen gas. It has not been found 
possible, however, to improve the efficiency or life of small lamps by 
this method; hence its commercial development is limited to lamps 
above 100 candle power. With the development of modern illuminants 
of high efficiency, much attention has been given to the artistic and 
scientific use of lamps. High efficiency lamps are for the most part of 
excessive brilliancy and require the use of some kind of diffusing 
medium to soften the light. In many cases a degree of diffusion 
approaching that of daylight has been sought by the complete con- 
cealment of the lamps within bowls or troughs which reflect the light 
upward to a white ceiling, whence it is distributed about the room. 
Semi-indirect lighting, in which the lamps are covered by transparent 
bowls of glass, which partially transmit the light downward and 
partially reflect it to a white ceiling, is considered by many a more 
satisfactory solution of the problem. 

Electric lighting is somewhat safer than gas or oil lamps as regards 
danger from fire, but it is so only if all rules and precautions advised 
by underwriters are strictly followed and observed. The wires should 
never be run in wooden mouldings, but must be carried in iron or brass 
"armored" conduits. The entire house installation must be tested by 
an expert electrician to guard against defects. In isolated lighting by 
electricity the plant may be located in the barn or in the water pumping 
station, if there is one, and comprises an engine or power motor (gasoline 
or oil engine or water power) and a dynamo or generator. In some 
cases storage batteries are installed in connection with the dynamo, 
insuring a steadier supply of electric current. 

WATER SUPPLY AND PLUMBING. 

The water supply of a dwelling should be plentiful for all require- 
ments, and its distribution should be so arranged that the supply for 
every room is easily accessible. When practicable, water-taps should 
be placed on every floor, both for convenience and for greater safety 
in case of fire. It is also the result of experience that personal habits 
of cleanliness increase in a direct ratio with the ease of obtaining water. 
The inmates of a house where water is obtainable with little exertion 
are much more likely to be cleanly in their habits than where the water 
supply is deficient or not readily procured. 

Plumbing. — In its broadest sense, plumbing includes the pipes and 
fixtures within houses used to supply water, gas, and heat, and also the 
pipes used to remove liquid waste from buildings. A more restricted 
jmd more common use of the term includes only the water supply and 




WATER SUPPLY AND PLUMBING 453 

house drainage system, leaving gas fitting and steam and hot water 
fitting in two separate classes— and it is in the former sense that it 
will here be considered. 

Supply. — The pipe leading from the street main to the building is 
called the house connection or service pipe and is frequently laid, at 
least as far as the curb or sidewalk line, by the water department. 
The service pipe, and the water pipe system within the house as well, 
may be of lead or wrought iron, or, if the building be large, the main 
piping may be of cast iron. In highly finished, expensive work, brass 
or nickel-plated pipe is sometimes used, and copper may be employed 
for hot water piping. As some waters slowly attack and decompose 
lead and give rise of lead poisoning, the materials for service and 
house piping should be chosen Avith care. A valve at the sidewalk 
enables the water department to turn on or shut off the water to the 
consumer at will, and another valve, just inside the cellar wall, permits 
the householder to control the house supply from that point on. The 
water meter, if employed, is generally placed just inside the latter 
shut-off valve. Except in the smaller and cheaper houses the water 
piping is mostly in duplicate, one set of pipes being for hot and one for 
cold water. The water is heated by circulating through a pipe or a 
water boiler at the rear of the kitchen range, from which it goes for 
storage to the kitchen or range boiler. Where large supplies of hot 
water are used a separate heater fired either by coal or gas may be 
employed, and in the latter case the burner is regulated automatically. 
These hot water boilers are made of wrought iron, steel, or copper, 
with riveted joints, and should be tested to withstand a high pressure." 
When the water supply is liable to be inadequate at times, or when the 
direct pressure is too heavy for safety to the plumbing, a tank is pro- 
vided in the upper part of the building, and in a sky-scraper there may 
be several sets of these tanks at different elevations. Tanks for the 
fire lines are often required for large buildings. Great care is necessary 
to secure and maintain water-tightness. Tanks must be provided with 
automatic valves to insure a constant supply therein and to prevent 
water going to the tanks when full ; also with overflow or waste pipes. 

Fixtures. — The various faucets, sinks, and other similar appliances 
connected tvith a plumbing system: Faucets, cocks, or valves are pro- 
vided at each place where water is to be drawn. It is important that 
these should be of high grade to prevent leakage. Sinks are provided in 
the kitchen, the butler's pantry, and in large houses and semi-public and 
public buildings, in various other places. Most commonly they are of 
iron and have hot and cold water. Laundry tubs are placed in a sep- 
arate room or in the kitchen, and consist of two or more rectangular 
compartments, with the front side sloping, provided with hot and cold 
water and composed of soapstone, artificial stone, cement, iron, earthen- 
ware, porcelain, or other material, with or without hinged covers. The 
chief essential in the material for laundry tubs is lack. of porosity; wood, 
on account of its high absorbing quality, is unsuitable. Set washbowls 
are provided in bath-rooms and lavatories, in the private rooms of 



i:>i 



HOUSING AND PLUMBING 



hotels, and sometimes in the sleeping rooms of private dwellings. At 
one time they were most commonly of marble, but cast iron and steel, 
both painted and enameled, and porcelain arc now more generally 
employed. Bath-tubs, once generally constructed of polished sheet 
copper, formed on wood, or of solid copper, are now made of enameled 
cast iron and of porcelain. Shower baths, sitz baths, and foot baths 
are sometimes added for the special purposes indicated and are made 
of different designs and materials. Water-closets, so called because 
matter deposited into them is flushed out by a discharge of water, are 
most commonly of glazed earthenware, although in cheap work cast 
iron is sometimes used. The old-fashioned pan water-closet was one 
of the most unsanitary of all plumbing fixtures. It consisted of a metal 
pan, hinged so as to drop dowmward and discharge its contents into the 




Fig. 70. — Open wash-out closet. (Harrington.) 



pipe with which it was connected. The valve and plunger closets, 
operated as indicated by their names, were but little better, and are 
also out of date. Most of the improved forms of water-closets now in 
use depend for their action upon the sudden discharge of a few gallons 
of water, generally from a tank located above the closet. The discharge 
is usually effected by pulling a hanging chain attached to a lever and 
valve. In the case of closets in public places the tanks may discharge 
automatically. Recently, however, attachments have been introduced 
for flushing w r ater-closets without the use of a tank, the water supply 
being controlled by a valve operated by a short lever, near the closet 
seat. In either case the water thus liberated displaces the water pre- 
viously standing in the bowl or hopper of the closet or else sets it in 
motion by siphonic action, carrying the wastes with it. By this means 




WATER SUPPLY AND PLUMBING 



455 



the closet, is kept fairly clean, particularly the most exposed portion, 
and the parts not thoroughly clean are always wet. Water-closet 
flush tanks are generally of wood, lined with copper and provided with 
a float valve, a water supply and a flush pipe. There is an almost 
endless variety of water-closets. Urinals are provided in public places 
and consist of either bowls or vertical slabs of non-porous material 
inclosed in stalls and provided with flushing water. Latrines are a 
series of water-closet stalls connected with a long trough or common 
flushing chamber below. They are employed chiefly for barracks and 
institutions. Sill or hose cocks are faucets or valves, with a provi- 
sion for attaching hose, provided at convenient points for sprinkling 
lawns, etc. 




mZ^q 



gm^:^^v.y^v^^^M 



Fig. 71. — Siphon jet closet. (Harrington.) 

House Sewerage or Drainage. — This includes everything required 
to remove fouled water from the house to the sewer. The pipes from 
each separate fixture are known as waste pipes ; they run to one or more 
soil pipes, the soil pipe being the vertical run of pipe from the highest 
fixture to the cellar; the house drain extends from the foot of the soil 
to a point near the cellar wall, and the house sewer from the latter point 
to the street sewer. Waste pipes, particularly short runs from wash- 
bowls and minor fixtures, may be of lead, but, generally speaking, cast 
or wrought iron is preferable for important wastes. All soil pipes and 
the house drain also should be of cast iron. Heavy pipe should be 
used throughout. The house sewer should be of extra heavy iron 
through and a short distance beyond the foundation, after which 
vitrified clay pipe is permissible. All soil and waste pipes should be 
carried up through the roof. Traps are placed below each fixture and 
a main trap is generally set just inside the cellar wall. All main traps 
should have fresh-air inlets or a pipe extending from the inner end of 



456 



HOUSING AND PLUMBING 



the trap to theouter air. This provides for a circulation of air through 
the house drain and soil pipe. An increasing number of sanitary 
engineers favor the omission of the main trap, thus insuring a thorough 
ventilation of the house and street sewerage system through the 




Fig. 72. — Preferable arrangement of intercepting trap and ventilating pipe. 

(Harrington.) 

numerous soil pipes at one extremity and the street manholes at the 
other. The object of the trap is to prevent foul air from the house or 
street sewerage system from entering the house. To this end the 
simplest and most common practice is to form a water seal by making 
a bend in the pipe, shaped like the letter U called the U-trap. Bell- 




FlG 



Forcing of seal of running trap. (Harrington.) 



traps are formed by inverting a bell or cup over the upper and open 
end of a pipe, the whole being adjusted so that the edge of the pipe is 
always submerged. (I reuse traps may be described as enlargements 
on waste pipes to retain grease instead of allowing it to pass on and 



WATER SUPPLY AND PLUMBING 



45: 



clog sewers. They are most commonly used on the water or drain pipes 
of large kitchens. Vent pipes were formerly run from the back of each 
trap to a connection with the outer air, to give a back air pressure on 




Fig. 74. — Bell trap. (Harrington.) 

the trap and lessen the danger from siphonage; trap vents are now 
omitted on much of the best work in the United States, as they compli- 
cate the plumbing system. Regarding the omission of both main traps 




Fig. 75. — Grease trap. (Harrington.) 



and trap vents it may be said that there is little need for them on well 
designed and built house and street sewerage systems, provided that 
non-siphoning traps are employed and the disposition of fixtures does 



168 HOUSING AND PLUMBING 

not necessitate long branch wastes without the aeration obtained from 
the vent pipe. 

/// general, simplicity, accessibility, a high grade of material through- 
out, heavy weight for pipes, and good workmanship are essentials of 
plumbing. To secure these, plumbing should be designed only by the 
most competent sanitary engineers and should be under the rigid super- 
vision of efficient municipal inspectors. All plans for plumbing should 
be filed with the plumbing inspectors or local health department. The 
hydraulic pressure test should be applied when the rough plumbing 
has been completed, and the smoke or peppermint test when the fixtures 
are set. 

Water closets presuppose an abundant supply of water. Unless this 
can be obtained and rendered available for flushing the closets, soil 
pipes, and house drains, the dry-earth or pail system should be adopted. 
Privies should not be countenanced. 

The inspection of plumbing entails chiefly provision against leaking 
around water-closets, sinks, etc. Sewer gas, once a hygienic bugaboo, 
is now not seriously regarded by sanitarians. 



CHAPTER XVIII. 

THE SANITATION OF SWIMMING POOLS. 1 

By WALLACE A. MANHEIMER, Ph.D. 

Swimming-pool sanitation has assumed importance with the recog- 
nition of the danger of swimming in polluted water and with the ever- 
increasing number of swimming pools throughout the country. Accord- 
ing to conservative estimates, there are upward of fifteen thousand 
swimming pools in the United States, exclusive of open air, salt water 
and wading pools. 

The problem of swimming-pool purification is largely the same as 
that of drinking-water purification, but differs from the latter in at 
least one important particular. In the purification of a water supply 
an initial treatment is usually sufficient, while in a swimming pool 
having a constant source of pollution a continuous method of purifica- 
tion has been found necessary. 

DISEASES TRANSMISSIBLE THROUGH SWIMMING IN POLLUTED 

WATER. 

Atkin 2 divides diseases transmissible through swimming pools into 
three classes, namely, intestinal, eye and ear, and venereal. To this 
there should be added a fourth class namely, respiratory. 

Intestinal. — Klein and Schutz 3 reported cases of typhoid fever in 
six soldiers who had bathed in water close to the mouth of the city 
drainage canal. In the discussion of a paper by Maier, 4 Dr. Reece 
reported the occurrence of 34 cases of enteric fever among soldiers who 
had bathed in a swimming pool which derived its water from a sewage- 
polluted river. About 10 per cent, of the men using the pool became 
infected, while only one case developed among those who did not use 
the pool. The epidemic ceased when bathing in the pool was dis- 
continued. 

In Japan, Shiga investigated an epidemic of 413 cases of dysentery 
in the village of Nutaknura. Near the town was a river in which 
bathing had been prohibited. When this restriction was removed 
hundreds of persons went swimming, and within four days the epi- 
demic broke out. It was found that the clothes and bedding of a 
person who had died of the disease had been washed in the water of the 

1 From the Research Laboratory, New York City, Department of Health. 

2 Proc. Illinois Water Supply Assn., 1911, hi, 33. 

3 Wien. med. Wchnschr., 1898, vi, 238. 

4 Proc. Med. and Chir Soc, London, 1908, ii, 227. 



160 S INITATIOK OF SWIMMING POOLS 

stream a short distance above the village. Shiga concluded that the 
epidemic was due to the ingestion of the river water by the bathers. 

Eye and Ear Infections. Infections of the eye and ear are quite 
common, as can be attested by the experience of all who have managed 
swimming pools. Fehr 1 tells of 20 cases of eye infection among patrons 
of a public swimming pool, and in one case reinfection as a result of 
subsequent swimming in the same pool. Schultz 2 reported 18 cases 
of eye infection among the young men who had used a public swim- 
ming pool which had been contaminated by an attendant who had 
sore eyes. 

Venereal Diseases. — Skutch 3 had reported an epidemic of gonorrheal 
vulvovaginitis which had spread to 236 girls in a school at Posen. They 
all had used the same swimming pool, but not the same towels, soap, 
etc. Paul Bending has given an instance of 15 cases of gonorrhea among 
forty girls who were sent to a brine bath for medicinal treatment. 
The infection came from an eight-year-old girl who apparently had 
been suffering from gonorrhea for several years. The disease was 
spread through indiscriminate bathing in one bath tub and the use 
of a common bath towel. 

Respiratory. — Epidemics of coryza among the users of swimming 
pools are not uncommon. It was indeed just such an epidemic which 
led Burrage 4 to undertake studies of methods to purify pools. Lewis, 5 
\Yhipple 6 and others have further advanced evidence that infections of 
the respiratory tract can result from bathing in contaminated water. 

CONSTRUCTION AND EQUIPMENT. 

We are not interested here with the engineering problem of swim- 
ming-pool construction. On the sanitary side, however, certain details 
become of obvious importance. 

Drainage. — The floor surrounding a swimming pool should be 
constructed of material impervious to water and so arranged that all 
water will drain into the sewer and not flow back into the pool. The 
edge of the pool should be protected from drainage water, either by a 
ledge or by a drainage groove. The perimeter of the pool should be 
provided with a surface overflow, so that debris on the surface of the 
water will flow off, and as an additional precaution against floor 
drainage. 

Materials of Construction. — Stone, marble, cement, painted sheet 
steel, and porcelain, or enamel brick and tile have been used in pool 
construction. Recently certain types of surfacing materials have been 
used with success and have reduced the cost of construction consider- 
ably. The requirements of materials in pool construction are: (1) light 

1 Berl. klin. Wchnschr., 1900, i, 37. 

2 Ibid., 1899, xxxix, 36. 

3 Central bl. f. Bakteriol., 1892, xii, 309. 

4 Proc. Indiana Acad, of Sc, 25th meeting, 1909. 
6 Engineering News, 1911, lxv, 689. 
c Municipal Jour, and Engineer, 1911, xxx, 577" 






CONSTRUCTION AND EQUIPMENT 461 

color, preferably white (so that a submerged person can readily be 
seen); (2) smooth or easily cleansable material; (3) imperviousness to 
water; (4) durability. 

For the floor surrounding the pool besides the materials mentioned 
above, cork, inlaid linoleum, wood-lattice and even rubber, have been 
used. A water-tight material is best, but some method to prevent 
the slipping of bathers is usually considered necessary. An ideal 
material for both floors and pool lining would be one that is durable, 
light colored, impervious to water, a poor conductor of heat, and sur- 
faced, so as to prevent slipping. So far as we know no such material 
is on the market at the present time. 

Equipment. — Descending ladders and stairs should be built into 
the pool so as to present no obstruction in the water. Life rails where 
provided should be of non-corrosible material and should be placed 
just at the surface of the water. With the application of surface over- 
flow gutters, life rails have been replaced by a combination overflow 
ledge and life rail. This is usually made of terra cotta, although metal 
gutters are occasionally used. 

Shower Baths. — An adequate number of shower baths, provided with 
hot water (except in outdoor baths where cold water is sufficient), 
should be supplied. In indoor pools used by women, shower baths 
should be placed in compartments where privacy during bathing can 
be maintained. The shower head should be directed at an angle. 
Partitions need not be higher than seven feet, but should be covered 
with durable wide-meshed wire. The impact, heat and friction of the 
water should be upon uncovered skin. The strongest agreeable 
pressure of water is the most efficient. Thermoregulation of the hot 
water (not to exceed 110° F. when it leaves the engine room) is necessary 
to prevent scalding. The showers taken by swimmers prior to entering 
a pool are hardly sufficient to wash from their bodies the harmless 
saprophytes that are on the skin and are ineffective in cleansing the 
perineal regions. For this purpose a douche from below might be 
satisfactory. So far as the writer knows no arrangement of this kind 
has been devised. 

Central control of the water supplied to the shower baths is necessary 
in handling large crowds. By turning the water on and off at regular 
intervals the dressing-room compartments and the showers can be 
emptied and thus used to the maximum capacity. 

Filters. — A proper filtering plant is of prime necessity in all indoor 
swimming pools. Even when the water from the mains is initially 
clear it is usually desirable to install a filter for the purpose of recir- 
culation or refiltration of the water. Any type of filter that will remove 
suspended matter from the water is usually satisfactory. Occasionally, 
however, it is necessary to bleach the water to prevent discoloration 
of the pool. 

Refiltration is used in swimming pools as a matter of economy, 
and when in conjunction with proper methods of water purification 
is an excellent sanitary measure. ^Yater and coal for heating are saved 



462 SANITATION OF SWIMMING POOLS 

by refiltration and the water maintained clearer than can usually be 
accomplished by initial filtration. The process of refiltration has 
proved so valuable in pool administration that it is now properly con- 
sidered a standard procedure. Clear water in swimming pools is very 
necessary to prevent drowning, since in dark waters submerged per- 
sons cannot be seen. A number of accidental drownings have occurred 
in pools where unfiltered water was used. 

Concerning the rate of filtration with mechanical filters a rate of 
two gallons of water per square foot of surface area of filter bed per 
minute is usually recommended for the clarifying of muddy and con- 
taminated waters. In actual practice, however, in swimming pools 
where water purifying devices are used in conjunction with filtration, 
a rate of three gallons can be handled with success. In general the 
highest rate of filtration which will remove suspended matter from 
the water may be used in swimming-pool filtration providing some 
system of water purification is also employed. 

CONTROL OF BATHERS. 

AYhere possible, bathers should be given periodical physical exami- 
nations for the purpose of excluding the diseased. In colleges and 
associations where a regularly registered body of people use the pool 
such examinations can be readily conducted, but in public swimming 
pools greater difficulties exist. For municipal baths, Manheimer has 
suggested organization and registration of the patrons, or the presen- 
tation of admission cards to be issued by the department of health after 
physical examination. The examinations given prior to the issuance 
of the card could be conducted on the general plan of that for the 
licensing of food handlers in the city of New York. 

In addition to medical supervision of bathers, signs should be posted 
and steps taken to instruct all of them in the proper use of the pool, 
e. g., the length of time to remain in the water, the necessity for pre- 
liminary shower baths in the nude, using soap, the importance of 
emptying the bladder before entering the pool and of abstaining from 
expectorating into the water, etc. 

Patrons should be compelled either to bathe nude or to wear sterilized 
bathing costumes provided by the establishment. 

MANAGEMENT OF THE WATER. 

Source of Water. — It is obvious that the water supplied to a swim- 
ming pool must be pure or be purified before use. Nevertheless 
inferior water is frequently used in swimming pools, as shown by 
Manheimer 1 in examinations of thirty-five swimming pools in various 
parts of New York State. Lake, river and creek water containing 
considerable amounts of sewage were used in eight out of the thirty- 
five pools studied. 

I \m. Phys. Ed, Rev., 1912, xvii, 009, 



MA^AGEMENT OF THE WATER 463 

Refilling. — The early writers on swimming pool sanitation, have 
dwelt almost exclusively on the importance of frequent refillings. 
Present writers on the subject emphasize the value of dilution and 
refiltration. 

Dilution and Refiltration. — The practice of adding warm filtered 
water while the swimming pool is in use is now quite common. The 
efficiency of this method of pool purification cannot be doubted, but it 
is extravagant of coal and water. Refiltration and continued use of 
the pool water has gradually supplanted the practice of adding fresh 
dilution water. 

As early as 1905 Furth and Schwarz began investigations on refil- 
tration. Kister and Fromme, 1 who review their data, highly recom- 
mend refiltration, not only as a method of water and heat conservation, 
but as an excellent sanitary measure. 

Disinfection. — Among the first attempts in this country at the 
chemical purification of swimming-pool water was that of Stokes, 2 
who used copper sulphate in a Baltimore swimming tank. Alexander, 3 
in 1909, reported satisfactory results from the use of magnesium hypo- 
chlorite. During the last few years a great deal of experimental work 
on swimming-pool disinfection has been reported. The obvious 
importance of this subject, together with the conflicting information 
published, has made necessary a critical study of the efficiency of 
various methods in use. 4 

Copper Sulphate. — Copper sulphate, as already stated, was the first 
chemical used to purify a swimming pool. Stokes used one part of 
CuS0 4 to 100,000 parts of water, which resulted in the reduction of 
bacteria and destruction of algae. Soon after, calcium hypochlorite 
displaced all other chemicals in pool purification and is now the most 
generally applied chemical for that purpose. 

Calcium Hypochlorite. — This has been used more extensively for 
pool purification than any other chemical. It is inexpensive, and under 
conditions of proper application is very reliable as a disinfectant. A 
concentration of one part of hypochlorite to 1,000,000 of water has 
proved to be the most satisfactory amount to add to the water. 

Concerning the method of adding the chemical to the water, Man- 
heimer 5 has found that the best results will be obtained when the 
chemical is added in a single dose, while with copper sulphate, contin- 
uous gradual addition from a mixing chamber proved superior. 

Although calcium hypochlorite has proved to be one of the most 
efficient chemicals for use in swimming pools, there are certain objec- 
tions to it, however, which must be considered: (1) The chemical 
itself is unstable. This would not be a serious objection if the various 
swimming-pool authorities had laboratory equipments and laboratory 

1 Kister and Fromme: Gsnhts. Ingenieur, 1910, xxx, 30. 

2 Am. Med., 1905, x, 1075. 

3 Scientific Am. Suppl., 1909, lxviii, 1765. 

4 Manheimer: Comparison of Methods for Disinfecting Swimming Pools, Jour. 
Inf. Dis., 1917, No. 1, xx. 

5 Jour. Inf. Dis., 1917, xx. 



i»> I SANITATION OF SWIMMING POOLS 

help for titrating the chemical from time to time. Very often a quan- 
tity of disinfectant is added to the water, based on determinations 
with a fresh sample and far too little to produce good results. (2) Cal- 
cium hypochlorite is difficult to handle so as to produce no odor in the 
air of the pool room. Also a considerable amount of insoluble inert 
"sludge" is left behind which causes objection when thrown into the 
pool. To prevent clogging of the filters the hypochlorite is usually 
mixed in a pail and the supernatant fluid thrown into the water. Many 
other methods of adding the chemical to the water have been suggested, 
e. g., the use of a feed pot on the filtration system, with a small bypass 
of water running through the hypochlorite solution and fed into the 
pool by the force of suction through a Venturi tube; the use of cheese- 
cloth bags filled with the reagent to be dragged through the water, etc. 
While many of these methods of adding the chemical to the water are 
satisfactory it is seldom that no odors are produced in the air and no 
odors and taste in the water. 

When we couple with the foregoing facts the smarting of the eyes 
of the bathers and the reduction in patronage of the pool which 
occasionally results we cannot conclude that hypochlorite sterilization 
of swimming pools is the ideal method to be recommended. In pools 
where careful supervision is maintained by a person with the proper 
technical training, calcium hypochlorite, and, for that matter, sodium 
hypochlorite and chlorin, can be used with excellent results. Usually, 
however, such supervision is not practised even in the very highest 
grade swimming pools, and so it has been found desirable to study 
automatic (" fool-proof") systems of pool purification. 

Sodium Hypochlorite and Chlorin are identical with calcium hypo- 
chlorite in their action. Sodium hypochlorite, according to Man- 
heimer, although more easily handled than calcium hypochlorite, 
is more expensive in application. Chlorin is inexpensive and much 
better to handle than either of the foregoing reagents', but it is diffi- 
cult to get a reliable chlorin injector. All of these chemicals present 
the same objections in practical application. 

Recently the applications of ultraviolet light and of ozone to pool 
purification have been made. Both of these processes are automatic 
in operation and eliminate the objections raised to the use of the 
halogens. 

Ultraviolet Light. — Ultraviolet light has proved to be an efficient 
water sterilizer, providing sufficient time of exposure of the water to 
the light is maintained. According to the experiments of Thresh and 
Beale 1 many bacteria are killed after an exposure of from five to twenty 
seconds and resisting spores in from thirty to sixty seconds. An 
exposure of from ten to twenty seconds was found necessary to kill 
B. typhosus and V. cholera. They found a clear water with the 
absence of color, colloidal matter, and turbidity to be essential to the 
efficiency of the rays. Galeotti 2 found that much longer times of 

1 Lancet, December 24, 1910. 

2 Ann. de l'lnst. Pasteur, 191G, No. 2, vol. xxx. 



MANAGEMENT OF THE WATER 465 

exposure were necessary to destroy bacteria in water. Using suspen- 
sions of B. pestis and V. cholera in physiological salt solution and plac- 
ing these suspensions on watch-glasses, so that the thickness of the 
suspension never exceeded 3 mm., Galeotti found it necessary to expose 
V. cholera for one minute and B. pestis from six to ten minutes. 

In Petrograd an ozone plant and an ultraviolet ray plant were running 
in competition for the purification of the city water supply. The ozone 
plant has been a complete success and the ultraviolet ray an absolute 
failure, due merely to the turbidity of the water. 1 Cobb, Williams and 
Letton, 2 in a study for the United States Public Health Service of 
commercial ultraviolet light machines used for water sterilization on 
the Great Lake steamers, could not recommend them. These investi- 
gators concluded that it is of doubtful possibility to obtain a sufficient 
intensity of light to destroy bacteria if the generating lamps were oper- 
ated at 110 volts or less. In addition to this they state: "It is essen- 
tial when using ultraviolet rays to have the water clear, as any slight 
turbidity will considerably reduce their efficiency, due to the fact that 
a certain number of the bacteria present in the water will be protected 
by the shadow caused by minutely suspended matter. . . . There 
is a tendency, especially with a hard water, such as the lake waters, 
for a certain amount of the mineral salts to deposit on the quartz tubes, 
such deposits rendering the tube more or less opaque to ultraviolet 
rays, hence lowering the efficiency of the lamps." M'anheimer 3 arrived 
at the conclusion, from a study on the application of the ultraviolet 
light to swimming-pool disinfection, that the time of exposure of the 
water to the light was insufficient to produce any marked bacterial 
reduction. The application of ultraviolet light in the purification of 
swimming pools to be effective would involve an increase in the 
number or size of the lamps with a corresponding increase in the cost 
of operation. 

Ozone. — Ozone is produced commercially by passing atmospheric 
oxygen through a field permeated with a silent electrical brush dis- 
charge. The application of ozone in water purification has assumed 
great importance, as is proved by the numerous instances of successful 
application. According to Spaulding there are forty-nine large ozone 
plants abroad, having a daily water delivery capacity of over 84,000,000 
gallons. The plant in Petrograd alone delivers 24,000,000 gallons a 
day and the plant at Paris over 12,000,000 gallons a day. 

Opinion concerning the value of ozone in water purification is 
practically unanimous. Rosenau 4 states: "Ozone is one of the most 
satisfactory methods of purifying water from a sanitary standpoint. 
As a germicide it is the most effective of all methods used except boiling. 
A well ozonated water is practically sterile and the organic matter is 
partially oxidized. It is true that a few resisting spores are not killed, 

1 Ozone, D. van Nostrand Co., 1916, p. 154. 

2 United States Public Health Report, October 13, 1916, p. 2S54. 

3 Jour. Inf. Dis., 1917, xx. 

4 Prevent. Med. and Hyg., p. 794. 
30 



466 SANITATION OF SWIMMING POOLS 

but these are harmless when taken into the mouth." Powell 1 in a 
comparative study on water disinfectants, concludes: "It is readily 
seen that the use of ozone as a sterilization agent is considerably more 
efficient than many of the other sterilizing agents used for water 
purification, at the same time, owing to the fact that it can be used 
efficiently with water containing turbidity and colors comparatively 
high, while the other sterilizing agents cannot be guaranteed to main- 
tain their efficiency under these conditions." 

The only published reports of the application of ozone to pool puri- , 
fication of which we know are those of Manheimer. 2 His experiments 
have proved that under the conditions which obtain in swimming pools 
ozone can be depended upon for efficient work and inexpensive appli- 
cation. Ozone takes precedence over all other chemicals in pool 
purification, because of its automatic control, reliability of action and 
unobjectionable presence in the water. When copper sulphate, chlorin, 
, sodium or calcium hypochlorites are used for swimming-pool disin- 
fection only minimum quantities may be used, because an excess of 
any of these chemicals produces a water with objectionable tastes and 
odors. Furthermore, technical skill, rarely available in the average 
swimming pool, is necessary to determine the exact quantities of these 
chemicals for use. With ozone, an excess of the amount necessary for 
purification can and should be used at all times, especially since no 
objectionable odors or taste will be caused thereby. Indeed, it is just 
this feature which makes the automatic application of ozone a possi- 
bility. 

The amount of ozone to be used for the purification of swimming- 
pool water is dependent on the time of exposure of the water to the 
ozone. If only a brief time of exposure is allowed a high concentration 
of ozone must be used. Obviously this increases the cost of application 
and causes a considerable waste of ozone. It should be remembered 
that ozone is not produced pure but in combination with air, in various 
concentrations. Since neither air nor ozone is soluble in water to any 
appreciable extent, thorough mechanical mixing of the ozonized air 
and water must be effected to ensure disinfection. Many methods of 
accomplishing this mixing have been devised, but it is safe to say that 
no method has been suitable to replace that of the liberation of the 
ozonized air at the bottom of tall water towers. Where towers of 
sufficient height are used a concentration of ozone in air sufficient to 
supply one part ozone to 1,000,000 parts of water is ample for pool 
water as well as for drinking-water purification. Careful experiments 
have been conducted for the purpose of ascertaining the best pro- 
portion of ozonized air to water, and the conclusion has been reached 
that at least twice as much ozonized air as water should be used. The 
air breaks up into fine bubbles while passing upward through the 
tower, the water forming thin films on the surface of the bubbles. 

1 .lour. Ing. and Eng. Chem., July, 1916, No. 7, vol. viii. 

2 U. S. Public Health Rep., March 1, 1918; Jour. Am. Med. Ass., June 29, 1918; 
Boston Med. and Surg. Jour., vol. clxxix, No. 21, p. 642. 



MIKVEHS 407 

The close proximity of all substances in the water to the ozonized air 
accounts for the efficient oxidation which results. 

Bacteriological Standards. — No bacteriological standard for swim- 
ming-pool water has been definitely proposed; nor is it likely that a 
figure for gross bacterial count will be generally accepted in view of 
the widely varying results reported by different investigators. 

For the water supplied to a pool, or used at a bathing beach, it has 
been generally felt that no water should be offered which does not 
conform with the bacterial standards for drinking water, at least after 
purification. That this view is not universally held, however, is evident 
from the regulations in the State of Illinois, where the widely variable 
conditions throughout the State are considered before disapproving a 
bathing place. "A count of five hundred bacteria per cubic centimeter 
and -colon bacilli not to present an excess of 25 per cent, in 1 c.c. por- 
tions" are the figures which are used as a basis of decision for the upper 
limit of pollution. 

The only locality where an upper limit is placed on bacterial contam- 
ination in a swimming pool is in New York City. Here the swimming 
pools are required to operate so that the number of colon bacilli per 
cubic centimeter in the water will not exceed ten. This seems to be a 
fair upper limit, to which swimming-pool water should be made to 
conform. The difficulty of deciding upon a definite bacterial count has 
given rise to the desire to standardize swimming-pool equipments and 
layouts, and modes of operation and administration. Indeed if a 
suitable equipment and plan of administration exist at a pool, it is 
safe to say that the pool will be maintained in a sanitary condition. 

MIKVEHS. 

Mikvehs, strictly defined, are Jewish ritual baths. The term 
Mikveh, however, as commonly used by the Jewish people, includes 
baths of similar type, though not always of a purely ritual nature. 
Accordingly, Mikvehs can be best classified as (1) sanctioned Mikvehs 
(true Mikvehs, sanctioned by Rabbis) or Jewish ritual baths for women, 
and (2) unsanctioned Mikvehs, divisible into (a) common Mikvehs or 
plunge baths operated at elevated temperatures and used as cleansing 
baths and (b) cold plunges operated in conjunction with Turkish 
sweat rooms. 

The first study of the sanitation of Mikvehs was that of Porter, 1 
who reported on their polluted condition. Subsequent studies by 
Manheimer 2 resulted in definite action by the Department of Health 
for the purpose of improving their condition. 

1. The Sanctioned Mikveh is the only true Mikveh, its use being a 
necessary part of Jewish ritual. Stringent Talmudic laws govern the 
use of the ritual plunge, which if carried out in letter and spirit would 
make sanitary inspection and control -of these baths entirely unneces- 

1 The Survey, July 27, 1912. 

2 The Survey: April 18, 1914, August 28, 1915; Jour. Iuf. Dis., vol. xv. No. 1, p. 159. 



4GS SANITATION OF SWIMMING POOLS 

sary. The ritual dip is required of women at all periods within seven 
days after menstruation, prior to certain holidays, before marriage, 
etc. Men are not required by religious law to take the ritual dip, 
although certain sects of Jewish people have acquired the custom of 
using the Mikveh as a semireligious practice. 

The sanctioned Mikveh, a tank usually of about 200 cubic feet capac- 
ity, is used by a relatively small number of people. A preliminary 
cleansing bath is required before the ritual dip is permitted, and con- 
sequently the water in this type of bath is usually in good condition. 
A careful regard for the management of the water, including its daily 
renewal, or more frequent renewal depending on the number of people 
using it, periodical 1 disinfection, together with the providing of clean 
towels, liquid soap, individual drinking cups, etc., should prove 
adequate to effect suitable sanitary conditions in these premises. 

(a) The Common Mikveh consists of a plunge bath of between 
200 and 400 cubic feet capacity, the water in which is maintained at 
an elevated temperature. This bath is frequented for the same reasons 
as Turkish baths, the Mikveh plunge being used as a common cleansing 
bath by a large number of people. The very nature of this type of 
bath precludes the possibility of its sanitary maintenance and the 
conclusion was reached that this type of pool should be abolished. 

(b) The Cold Mikveh, operated in conjunction with Turkish sweat 
rooms, falls into the category of swimming pools and should be con- 
trolled in like manner. Unfortunately, these pools are operated in 
conjunction with establishments where the general sanitary conditions 
are bad. Insufficient ventilation, soiled linen on beds and couches, 
common combs, brushes, drinking cups, etc., and the existence of 
dangerous conditions of fire hazard are the chief matters reported. 

LAWS. 

The States of Idaho, Louisiana and New York have passed laws 
governing the conduct of swimming pools. The States of California 
and Utah have recently introduced laws which at the time of this 
writing are under consideration for passage. The cities of San Fran- 
cisco, Saginaw, Albany, New York, Salt Lake City, and Seattle have 
also passed regulations on swimming pools. Portland, Oregon, has 
recently introduced and passed ordinances relating to this subject. 
While many States and municipalities have no specific laws or ordi- 
nances relating to swimming pools, many have passed regulations 
to which the pools must conform and which are tantamount to laws. 
Many localities are considering the formulation of laws and ordinances 
on swimming pools and a brief description of the field to be covered 
by them may be useful. 

Standards for Swimming-pool Legislation. 2 — No attempt is made to 
set forth regulations; merely tentative standards are proposed, up to 

1 For a full discussion of tbia .subject see Manheimer: "Sanitary Condition of Mik- 
vchs and Turkish Baths," Medical Record, February 2, 1918. 

2 Manheimer: Medical Record, March 9, 1918. 






LAWS 469 

which the laws should measure. The language of the ordinances will 
vary in the different localities and modification of details may be called 
for as a result of different local conditions. 

The standards suggested can be conveniently classified as: (1) those 
concerning the management of the water, (2) those relating to con- 
struction, safety devices and fire hazard and (3) sanitary control of 
premises and bathers. 

1. Standards Concerning the Management of the Water. — 1. The 
bacterial contents of the water supplied to a swimming pool must 
conform with that of drinking water, or if polluted, must be disinfected 
before use. 

2. The water in the swimming pool during use must be continuously 
diluted by adding fresh water, or, better, by reusing the water from 
the swimming pool after filtration and purification. 

3. The water must be maintained clear at all times to an extent at 
least sufficient to see a submerged person in any part of the pool. 

4. The water must be either periodically and regularly or contin- 
uously disinfected, unless emptied daily. The bacterial count must 
not exceed 10 colon bacilli per cubic centimeter. 

5. The method of disinfection must be satisfactory to the Depart- 
ment of Health. 

6. The water from the pool must, when discharged cause no con- 
tamination of any stream used for drinking purposes and should, if 
possible, be disposed of as sewage water. 

II. Standards Concerning the Construction of Pools, etc, — 1. The lining 
of the pool must be white (or nearly so), smooth (readily cleansable) 
and impervious to water. The corners of the pool should be rounded. 

2. There must be no obstructions in the water. Stairs and stair 
supports must be of metal or stone. 

3. Water from the floor surrounding the pool must not drain back 
into the pool. 

4. The floor must be constructed of material impervious to w^ater, 
must be adequately drained and composed of material designed to 
prevent slipping and, if possible, a poor conductor of heat. 

5. There must be a scum gutter on at least tw T o opposite sides of the 
pool, and preferably completely surrounding the pool, for the purpose 
of draining off the surface dirt and of affording a place for bathers 
to spit. The scum-gutter must drain into the sew T er or cesspool and 
not back into the recirculation system. 

6. Construction should be made with due regard to the elimination 
of fire hazards, taking into account the providing of sufficient exits to 
accommodate the largest crow T d that w r ould be likely to attend exhi- 
bitions, etc. 

7. The pool should be shallow at one end and deep enough at the 
other to permit diving wdth safety, unless constructed as a wading 
pool for children. 

8. Dressing-room compartments in indoor pools must be con- 
structed vermin-proof. 



170 SANITATION OF SWIMMING POOLS 

\l Bathing establishments should be under permit of the Depart- 
ment of Health to include construction and operation. 

10. Adequate shower-bath and toilet facilities must be provided; 
also hot water for showers in indoor pools. Toilets must be screened 
against Hies, unless water-Hushed and covered by toilet lids. 

1 1 . Sanitary drinking fountains with pure water must be supplied. 
III. Sanitary Control of Premises and Bathers, etc. — 1. Adequate 

light and ventilation must be provided. 

2. A temperature of the air during the winter in indoor pools of 
between 70° and 80° F., must be maintained. 1 

3. No common towels, combs, brushes or drinking cups may be 
provided. 

4. All tow T els, suits, etc., provided by the establishment for public 
use must be sterilized after each separate use. 

5. Anti-spit signs must be conspicuously posted. Signs in large 
letters must be posted in dressing compartments directing all bathers, 
men and women, to take a preliminary cleansing shower in the nude 
with warm water and soap and to empty the bladder before going into 
the pool. Bathers must rinse off all soap before entering the pool 
room. 

6. No diseased or intoxicated person should be permitted to use a 
swimming pool. 

7. Only those persons dressed or undressed for bathing may enter 
the pool room. 

8. Men and boys must bathe in the nude or be provided with sterilized 
suits. Suits for men and w^omen must be of fast color and of a lintless 
material. 

9. A lifeguard must be present at all times. He must be acquainted 
with the technic of resuscitation of the apparently drowned and have 
equipment at hand for rescuing and resuscitating. He, or some 
attendent must supervise the incoming bathers to enforce the regula- 
tion concerning the preliminary bath and to exclude undesirable and 
diseased persons. 

10. The room must be locked during the emptying and refilling of 
the pool (or other steps be taken), so that bathers will not dive into 
an empty pool. 

11. The pool w T hen emptied must be well scrubbed. 

12. No smoking should be allowed in indoor pools. 

13. Cuspidors must be provided in the dressing rooms and pool 
rooms. 

14. If tub baths are supplied they must be disinfected after each 
separate use. 

1 It is usually deemed necessary to maintain a higher temperature in bath buildings, 
than in living rooms, school rooms, etc. 



CHAPTER XIX. 

PERSONAL HYGIENE. 

By EUGENE LYMAN FISK, M.D. 

In the early stages of public health work, the health officer was 
confronted with formidable and often insoluble problems relating 
to the prevention or eradication of communicable disease. With the 
growth of knowledge as to the causation of these maladies, the task 
of the health officer in the protection of the community has been much 
simplified. 

While the prevention and stamping out of communicable disease 
still makes heavy demands upon the resourcefulness and scientific 
equipment of the health officer, his problems in this relation are so 
simplified that a by-product of tremendous value would be wasted 
if the opportunity more completely to safeguard the public health 
by education in personal hygiene were neglected. In fact, so tremen- 
dous is the opportunity in this direction offered the public health 
officer that instead of his work dwindling in importance as methods 
of sanitary control and the prevention of epidemic disease become 
standardized and easily applied, it may be said to have greatly broad- 
ened and also risen to a greater dignity and importance in its possible 
influence on human life and public welfare. While here and there 
some reactionary may object to such activities on the part of the 
health officer, the enlightened tax-paying citizen will be very grateful 
to such an official for making readily available, the knowledge of how 
to live so that illness, physical inefficiency and premature breakdown 
may be avoided. It is surely quite as much a proper function of 
public health administration to acquaint the people with the dangers 
of overfeeding as it is to protect the community from adulterated and 
impure food. Without in the least belittling the good results of the 
administration of pure food laws, it is conservative to state that 
more injury has been sustained by the public through improper feeding 
than through adulterated food. 

The family physician who warns his patient does not always receive 
attention, but the utterance of an official health department will 
in time command public attention and gradually mold public opinion 
in a way that cannot be done by the scattered, unstandardized and 
varying efforts of individual physicians. The health officer who is 
alive to these opportunities and desirous of improving them will do 
well carefully to survey the field of knowledge on these subjects and 
plan his educational campaign along systematic lines, following no 



172 PERSONAL HYGIENE 

fads and marshalling adequate scientific support to the principles 
inculcated. At the outset it is important to obtain a correct view- 
point of tlie possibilities of this work and of the ultimate goal that 
should be its object. 

WHAT IS PERSONAL HYGIENE? 

Personal or individual hygiene implies "high ideals of health, 
strength, endurance, symmetry and beauty; it enormously increases 
our capacity to work, to be happy, and to be useful; it develops, 
not only the body, but the mind and the heart; it ennobles the man as 
a whole." 

In order to be free to carry forward this work with proper flexibility 
and openness of mind, it is necessary to rid ourselves of much accu- 
mulated tradition and of the paralyzing influence of the classification 
and terminology of disease. Current classifications of disease still 
reflect the influence of the outworn theory that diseases are entities 
arising without specific cause, afflictions in the nature of "acts of 
God." There is needed a thorough revision of the classification of 
disease with more attention to etiology. As one general disease after 
another is found to be actually due to infection, we are led closely to 
analyze all forms of physical deterioration or impairment, and as we 
do this we are led to see the folly of regarding any form of disease as 
self-initiated, as having any possibilities of progression without the 
continuous operation of some specific cause or group of causes. As 
our vision clears on these points, we are led to seek and analyze these 
causes with greater precision, and we have forced upon us the con- 
viction that the term disease is a misleading one, that in so-called 
disease, we are dealing with an organism manifesting various forms of 
impairment, tissue change or disturbance of function. Whether these 
changes rise to the dignity of a disease is partly a matter of degree and 
partly a matter of opinion. 

^Yhen a man's kidneys and circulation prove obviously insufficient we 
label him as having "Bright's disease." Slowly developing changes 
may have been taking place in his tissues for many years, not because 
he had Bright' s disease, but because some one or more of a group of 
possible causes had been at work on his body. It will be helpful in 
clarifying this subject to group the various factors or types of influ- 
ences that are responsible for physical deterioration, substandard 
health conditions, chronic disease, premature old age and death. 

1. Heredity. 

2. Physical strain. Muscular excess and organic strain. Mental 
and emotional strain or imbalance. 

3. Physical apathy, muscular disuse, faulty physical posture, skin 
disuse (improper clothing). Mental and emotional apathy, and disuse, 
faulty mental posture. 

4. Food excess, quantitative, and qualitative. Food deficiency, quan- 
titative and qualitative (food accessories). Hormone deficiency. 



WHAT IS PERSONAL HYGIENE 473 

5. Poisoning: 

Drugs. 

Metabolic poisons. 
True auto-intoxication. 
Hormone excess. 

6. Infections, bacterial and parasitic. 

Focal: Teeth, tonsils, sinuses, urethra, seminal vesicles, etc. 
General: Syphilis, typhoid, tuberculosis and all communicable 
diseases. 

7. Trauma, mental and physical. 

In the above probably infection plays the largest part. Mayo has 
truly said: "Life is one long struggle with microorganisms." 

A careful consideration of these causative factors, clears the way 
for a formulation of the fundamental principles of personal hygiene 
which can be brought into play for the most complete protection 
of the individual as well as for the up-building of his health. 

The first great commandment in personal hygiene is to have your 
body periodically examined so that the rules of hygiene may be 
applied with precision. Exercise, diet, all may be without avail if 
you are working against a septic tonsil or a tooth abscess. What has 
built up your neighbor may break down your own health. After your 
physical condition is ascertained, the following rides of hygiene as 
prescribed in the Institute's book How to Live, may be taken as a 
suggestive sjuide. 

(a) Air. 

1. Ventilate every room you occupy. 

2. Wear light, loose and porous clothes. 

3. Seek out-door occupations and recreations. 

4. Sleep out if you can. 

5. Breathe deeplv. 
(6) Food. 

6. Avoid overeating and overweight. 

7. Eat sparingly of meats and eggs. 

8. Eat some hard, some bulky, some raw foods. 

9. Eat slowly. 

(c) Poisons. 

10. Evacuate thoroughly, regularly and frequently. 

11. Stand, sit and walk erect. 

12. Do not allow poisons and infections to enter the body. 

13. Keep the teeth, gums and tongue clean. 

14. Use sufficient water internally and externally. 

(d) Activity. 

15. Work, play, rest and sleep in moderation. 

16. Keep serene. 

A great deal of harm has been done by well-meaning people seeking 
to educate the public in right living. It happens all too frequently 
that an enthusiastic health reformer will take up some particular 
phase of personal hygiene and not only overemphasize its value but in 



17 f 



personal hygiene 






endeavoring to group all conditions of ill-health under its possible 
curative or preventive influence, discredit the whole movement for 
rational health reform. Well-balanced personal hygiene involves a 
practice of each phase of right living. There is no magic system of 
exercise, of diet, of mental hygiene, of psychotherapeutics, the practice 
of which alone will lead to perfect health. 

While it is true that the health officer must rely chiefly upon edu- 
cational methods in guiding the hygiene of the people, he can, never- 
theless, emphasize as one of the fundamental requirements in intelli- 
gently applying the laws of right living, that people from early child- 
hood on should be subjected to periodic physical examination so that 
individual needs and idiosyncrasies can be given due consideration in 
applying the various rules of hygienic living. The calm and supine 
acceptance of the seven ages of man as an inevitable limitation upon 
humanity is, of course, paralleled by many other ages-old abuses and 
traditions which have burdened the human race. In the past decade, 
however, the idea of periodically examining the human machine has 
gained great support. It is now very widely talked about although 
its benefits are only extended to a comparatively small number of 
people in proportion to the total population. 

Pioneer Work. — The first great experiment along these lines on 
any large scale was tried in an insurance company about nine years 
ago with results so startling that the proposal to extend such benefits 
to policy-holders generally was readily entertained by a group of 
scientific men and publicists who established the Life Extension 
Institute in 1914. A number of companies now extend this privilege 
of periodical examination and hygienic guidance by the Institute to 
their policy-holders. The practice of physical examination of employees 
before employment and thereafter has expanded quite widely and is 
now a matter of vital interest pertaining to the welfare and efficiency 
of industrial employees. 

EXAMINATION OF INDUSTRIAL AND COMMERCIAL EMPLOYEES. 

Industrial men, Commercial men, 

average age average age 

of 34 years. of 26 years. 

Per cent. Per cent. 

Class 1. No physical impairment reported and no 

modification of living habits required . 

Class 2. Slight physical impairment or defects 
requiring observation or hygienic 
guidance 10 10 

Class 3. Moderate physical impairment or defect 
requiring some form of hygienic guid- 
ance or minor medical, dental or surgi- 
cal treatment 41 52 

Class 4. Moderate physical impairment or defect, 
medical supervision or treatment ad- 
vised, in addition to hygienic guidance 35 27 

( lass 5. Advanced physical impairment or defect 
requiring systematic medical supervi- 
sion or treatment 9 9 

("lass 6. Serious physical impairment or defect 
urgently demanding immediate atten- 
tion 5 2 



WHAT IS PERSONAL HYGIENE 475 

The Life Extension Institute has examined about 150,000 people, 
more than half of whom have been found showing impairments or 
functional derangements of a character that would warrant medical 
or surgical attention. 

The analysis on page 479 showing the results of the Life Extension 
Institute's examinations among some thousands of industrial and 
commercial employees actively at work, enables us to tak? a " birds' 
eye view," as it were, of the physical condition of civilized man. 

In the examination by especially trained examiners of 5000 indi- 
viduals in various walks of life, people who in the mass regarded them- 
selves as in fairly good condition, but were nevertheless moved to 
seek a service that would improve their state of health and lengthen 
their lives, the following percentages were found: 



Ages. 


*Class 1. 


Class 2. 


Class 3. 


Class 4. 


Class 5. 


Class 6. 






Percent. 


Per cent. 


Per cent. 


Percent. 


Percent. 


Percent. 


Per cent. 


Under 25 . 





.003 


27 


32 


37 


4 


100 


25 to 44 





.001 


18 


28 


46 


8 


100 


45 to 64 








11 


22 


55 


12 


100 


65 and over 








6 


15 


60 


19 


100 



These figures when first published were looked upon with some skepti- 
cism by many w T ho were attuned to the results obtained in ordinary 
physical examinations which were not standardized and did not aim 
rigorously to cover each region of the body even though no condition 
of illness was apparent. Sentiment has very materially changed in 
this regard, however, since the publication of the results of the draft 
examinations. Although the most favorable age group in the popu- 
lation, that between twenty-one and thirty-one was taken, 34 per 

Death-rate per 1000 Living White Males. 

36. D.R. 




D.R. 2 _ 4 



AGES 12 20 30 40 50 60 

Fig. 76. — United States life tables, census of 1910. 
* These classifications identical with the preceding. 



476 



PERSONAL HYGIENE 



cent . were declined in the first draft as physically unfit. (This includes 
those rejected at the camps.) An analysis of seven boards made 
by the writer showed the following causes of rejection: 



ANALYSIS OF SEVEN LOCAL BOARDS IN DETROIT, BROOKLYN AND 

NEW YORK. 

Percentage 
of those 
Number. examined. 

Number of men called 8875 .... 

Number of men examined 7611 .... 

Number of men discharged for physical reasons . . 2232 29. 

Prominent causes of rejection: 

Defective eyes 462 6. 

Defective teeth £66 4.8 

Underweight 350 4.6 

Hernia 223 2.9 

Heart defects 184 2.4 

Defective feet 180 2.3 

Injured or amputated limbs 169 2.2 

Defective ears 88 1.2 

Tuberculosis of lungs 77 1. 

Tuberculosis of joints 2 .... 

Undersize 53 0.7 

Genito-urinary bladder, etc 37 0.5 

Varicose veins 35 0.4 

Overweight 32 0.4 

Syphilis. . . . .' 32 0.4 

Varicocele 28 0.3 

Deformity of trunk 38 0.5 

Asthma, bronchitis, etc 21 0.3 

Mental and insane 14 0.2 

Debility and poor physique 16 0.2 

Miscellaneous injuries 15 0.2 

Hemorrhoids 13 0.2 

Kidney disease 10 0.1 

Rheumatism 8 0.1 

Miscellaneous defects 7 0.1 

Epilepsy 7 0.1 

Fistula 5 0.06 

Alcoholism 4 0.05 

Hydrocele 4 0.05 

Diabetes 4 0.05 

Goiter 6 0.08 

Deaf mutes 6 . 08 

Skin 4 0.05 

Liver and gall-bladder 3 0.04 

Drug habit 3 0,04 

Injury to nervous system 3 0.04 

Kidney removed 2 . 02 

Neurasthenia 1 0.01 

When it is considered that many men were sent up to the canton- 
ments who were really physically unfit and had minor defects which 
could be corrected, and that the vast majority that were accepted 
required a great deal of physical training and hardening before they 
were considered fit to be sent abroad (47 per cent, of those exam- 
ined showed some form of defect), it can be readily seen that the 
findings of the Life Extension Institute were consistent with those of 
the draft findings, making due allowance for the fact that the draft 
examinations were necessarily hurried and incomplete, inasmuch as a 
single cause of rejection was sufficient to act upon without further 



WHAT IS PERSONAL HYGIENE 477 

analysis. Later drafts showed similar conditions, although many with 
remediable defects were accepted and sent to the cantonments in view 
of the special provision that had been made for such work following 
the first draft. 

An analysis of the causes of rejection in the U. S. Marine Corps 
reveals similar conditions of human impairment. 

ANALYSIS OF PHYSICAL CAUSES FOR REJECTION FOR MILITARY SERVICE, 
U. S. NAVY AND MARINE CORPS, 1916 (REPORT OF SURGEON-GENERAL). 

Percentage of 
Number. men examined. 

Number of applicants 113,932 

Number of men examined 82,592 

Number of men rejected for all causes .... 51,167 62.00 

Causes of rejection: 

Eye defects 9,452 

Underweight 5,397 

Flat-foot 5,028 

Defective teeth 4,878 

Deformities 3,533 

Varicocele or varicose veins 3,105 

Heart affections 2,302 

Height, under 2,124 

Poor physique 1,633 

Ear defects 1,376 

Genito-urinary, venereal 1,347 

Hernia or tendency to 1,312 

Skin disease 1,094 

Height and weight, under 921 

Tuberculosis or suspects 909 

Pyorrhea 896 

Tonsillar conditions 588 

Genito-urinary, non-venereal 548 

Nasal abnormalities 476 

Febrile conditions 381 

Mental disorders 302 

Goiter or tendency to 294 

Defective speech 132 

Miscellaneous causes 2,820 

These physical insufficiencies of our adult male population clearly 
show the tremendous opportunity for preventive work, for repair work 
and for constructive work. They also show that not only is there an 
opportunity to do this work but that it must be done if we are success- 
fully to carry forward our civilization. 

An interesting experiment along these lines has been carried on 
in North Carolina by the State Health Commissioner, Dr. Rankin. 
A physician trained in the head office of the Life Extension Institute 
to work along standardized lines has been making physical examination 
of adults in certain counties under the joint auspices of the State 
Health Department and the county, its purpose being to discover 
evidence of chronic disease and physical deterioration. The results 
of these examinations are consistent with the findings of the Life 
Extension Institute and have served as a valuable stimulus to personal 
hygiene and to careful diagnostic work in the communities affected, 
This work is to be carried on through the State, 



11 


40 


6.50 


6 


08 


5 


90 


4 


30 


3 


SO 


2 


80 


2 


60 


2 


00 


1 


70 


1 


60 


1 


60 


1 


30 


1 


10 


1 


10 


1 


08 





72 





66 





57 





46 





36 





35 





15 


3 


41 



478 PERSONAL HYGIENE 

Periodic health examinations are now the rule in the New York 
City Health Department and have resulted in distinctly lowering the 
sickness rate. 

More and more there is a tendency on the part of city and State 
health departments to enter the field of work dealing with the influ- 
ences that bring about chronic diseases. The New York State Health 
Department has entered on an extensive campaign throughout the 
State by means of exhibits and bulletins dealing with the diseases of 
adult life and their prevention by proper living habits and especially 
by periodical health examinations. 

The question as to whether this physical deterioration is on the 
increase or decrease has been much debated. It is unfortunate that 
our census statistics until very recent years were so inadequate, that 
it is difficult to carry backward a statistically accurate comparison, 
yet when due allowance is made for all possible fallacies, for the 
incompleteness of the records, as well as for changes in classification 
and advance in diagnosis, etc., there seems evident a tendency to an 
increase in the chronic organic diseases which is also reflected in an 
increase in the mortality in the later decades of life. 

DEATH-RATE PER 10,000 LIVING — HEART, BLOODVESSELS, KIDNEYS. 

England and Wales. U. S. Registration area. 

1890. 1900. 1910. 1914. 1890. 1900. ' 1910. 1915. 

30 29 26 30 27 33 38 39 

The above table may be accepted as fairly revealing the general 
trend of mortality in this class of disease. Critics of this view- 
point have claimed that this apparent increase is due to changes in 
classification, to improvement in diagnosis, to influx of immigration. 
Making due allowance for all such possible influences the writer has 
been unable materially to affect or alter the evidence as to the increased 
mortality from these maladies as shown in the above table. The 
trend of mortality in Sweden, Denmark and Prussia has been in the 
direction of improvement at every age period of life. There was a 
similar trend in England and Wales until the past few years, when the 
war has rendered comparisons unsafe. An upward trend in these 
maladies is shown in England and Wales and likewise an increase in 
mortality in later age periods during the past few years. The fact 
should be borne in mind that in this country a totally different line 
of research, that seeking to ascertain the mortality by age periods, gives 
consistent results, pointing toward at least a failure to effect any 
saving of life in the later age periods. The downward sweep of the 
communicable diseases cannot be disputed. To this, and to the saving 
in child life must be ascribed the consistent and steady fall in the 
general death-rate. Putting these debatable questions aside, however, 
no one can question the fact that there is widespread physical impair- 
ment and physical insufficiency and that no further incentive is needed 
to impel us to the most vigorous effort in the direction of improving 
the physical resistance of the race. 



PRINCIPLES OF CORRECT DIET 479 



PRINCIPLES OF CORRECT DIET. 



Public instruction on diet should relate not merely to the common 
errors, such as overfeeding, underfeeding, excess of protein, vitamine 
deficiency and the like, but should aim to convey knowledge of the 
simple fundamental principles of correct diet and of the nutritional 
needs of the body. The individual should be taught to think for 
himself and intelligently govern his own diet without the need of 
didactic warnings and admonitions. 

While there are many unsettled problems in dietetics the main 
facts required for the guidance of individuals under ordinary living 
conditions are well established and the principles of their application 
are so simple that to be ignorant on this matter is inexcusable. We 
may confidently expect that the average schoolchild of the next 
generation will know more about diet than the average physician 
of today. 

The war has greatly extended the knowledge even of leading physiol- 
ogists with regard to the principles of nutrition. There is no longer 
any dispute as to the sufficiency of the Chittenden low protein 
standard. War experience has settled this debate which was rapidly 
becoming academic. Benedict's recent experiment at the Nutrition 
Laboratory of the Carnegie Institution, with a diet squad placed on a 
low calory war ration of 1400 calories per diem, has likewise shown 
that the basal metabolism formerly fixed by him was not an irreducible 
mininium and could be lowered about 30 per cent, when the body had 
become adjusted to a reduced ration and a lower heat production. 

This experiment has been covered in a report entitled "The Effects 
of a Prolonged Reduced Diet on Twenty-five College Men," by 
Francis G. Benedict, Walter R. Miles, Paul Roth and H. Monmouth 
Smith. 

In no field of personal hygiene is it more important carefully to 
search the recent literature, and especially that of physiological 
research, in order to base instruction upon demonstrated truths or at 
least upon the latest consensus of scientific judgment. The checking 
up of theories, and especially those in text -books which are often out 
of date before they are published is extremely important. Much 
popular educational matter on health is inaccurate and unbalanced 
for lack of this precaution. 

While public instruction cannot be loaded down with qualifications, 
possible fallacies, alternative theories, etc., but must be as simple and 
direct as possible and perhaps often a little more dogmatic in its 
tone than would be warranted in purely scientific discussion, unsettled 
theories should be stated as such and the trend of the best opinion 
set forth. There is nothing so discouraging to the public mind as to 
have a heralded scientific theory completely reversed. There is a 
happy medium in these matters which the health educator should 
endeavor to attain. 



4S0 PERSONAL HYGIENE 

The health officer will need to safeguard the public in the matter of 
diet chiefly along the following lines: 

Undernutrition or badly balanced nutrition in childhood. 

Overnutrition or badly balanced nutrition in adult life. 

Wastefid expenditure for food. 

Faulty eating habits. Neglect of the psychic value of eating. 

Faulty and wasteful preparation of food. 

Any attempt to educate the public in a mathematical prescription of 
diet as to calories, proteins, etc., is, in the author's opinion, unwise. 
The constitution of various food substances as to calories, minerals, 
etc., it is well to know, but it is far more important for an individual 
to weigh his body than to weigh his food or count his calories. Know- 
ing the low and high calory foods, his consumption of these can be 
governed according to his weight and not according to his theoretical 
requirements. His actual individual requirements can really only be 
determined in advance in a respiration calorimeter. 

As a suggestive model for simple popular instruction on dietetic 
principles, the following, taken from the book How to Live of the 
Life Extension Institute may prove of value. 

The Fundamental Principles of Correct Eating. — The human body 
is very much like an engine. It needs fuel to keep it running. As 
it has to be built so must it be repaired from time to time, also it 
must be regulated, hence, we need (a) fuel food, (6) building or repair 
food, (c) regulating food. 

Fuel Foods. — As in the case of an engine, the main requirement is 
for fuel. Unlike an engine, however, if the human body does not 
secure sufficient fuel it will literally burn to death, the tissues being 
drawn upon to supply the fuel. On the other hand, the human engine 
may easily become overstoked by an excess of fuel. The following 
list show r s the main fuel foods, the great foundation foods of the diet, 
that supply energy for muscular work. Mental work requires so 
little extra fuel that it is not necessary to consider specially. There 
are three groups of fuel foods. Here they are in the order of their cost 
per calory, those giving most energy for the money heading the list : 

1. Starchy foods: Cornmeal, hominy, broken rice, oatmeal, flour, 
rice, macaroni, sphaghetti, cornstarch, dried lima beans, split peas 
(yellow), dried navy beans, bread, potatoes, bananas. 

2. Sugars: Sugar, corn syrup, dates, candy, molasses, most fruits. 

3. Fats: Oleomargarine, nutmargarine, drippings, lard, salt pork, 
peanut butter, milk, bacon, butter and cream. 

About 85 per cent, of the fuel for the body should come from these 
groups, using starchy foods in the largest amount, fats next and sugars 
least. 

Building and Repair Foods. — These are divided into proteins and 
mineral salts. 

1. Proteins or "Body Bricks." — These food elements are found in 
greatest abundance in lean meat of all sorts (including fish, shell food 
and fowl), milk, cheese, eggs, peas and beans, lentils and nuts. There 



PRINCIPLES OF CORRECT DIET 481 

is also a fair amount of protein in cereals and bread (about 10 per cent.), 
which are both building and fuel foods. Most foods contain some 
protein. Those above mentioned are richest in protein and hence are 
termed "building" or "repair foods." 

The following is a list of the building and repair foods in the order 
of their cost, those giving most building and repair material for the 
money heading the list: 

Beans (dried white), dried peas, oatmeal, cornmeal, beans (dried 
lima), bread, bread (whole wheat), bread (Graham), salt cod, milk 
(skimmed), Cheese (American), peanuts, macaroni, mutton (leg), beef 
(lean rump), milk, beef (lean round), lamb (leg), eggs (2d grade), 
halibut, porterhouse steak, eggs (1st grade), almonds (shelled). 

2. Mineral Salts. — These are found in milk, green vegetables, fruit, 
cereals made from the whole grains and egg yolks. 

Regulating Foods. — 1. Mineral Salts. — These minerals which have 
been mentioned as repair foods, are also regulating foods, and help to 
keep the body machinery running properly. 

2. Water. — Water is an important regulating food. Many people 
drink too little. Six glasses of water a day is the average require- 
ment — one between meals and one at meals. 

3. Ballast or Bulk. — This is furnished by cereals and vegetable fiber, 
which is found in whole wheat or Graham flour, in bran, leaves and 
skins of plants and skins and pulp of fruits. Examples are: Vege- 
tables — peas, beans, lettuce, watercress, endive, parsnips, carrots, 
turnips, turnip tops, celery, oyster plant, cabbage, Brussels sprouts, 
tomatoes, salsify, Spanish onions, spinach, beet tops, kale, dandelions. 
Fruit — apples (baked or raw), pears, currants, raspberries, cranberries, 
prunes, dates, figs, oranges. 

4. Hard Foods. Vigorous use of teeth and jaws is insured by hard 
foods, such as crusts, hard crackers, toast, Zwieback, fibrous vegetables 
and fruits, celery and nuts, which are necessary to keep the teeth and 
gums in a healthy condition. 

5. Accessories or J^itamines. — These are minute substances present 
in varying amounts in a large variety of foods and apparently 
necessary to keep the body in health. That is, the absence of these 
substances seems to lead to poisoning of the body, which results in 
such disturbances as scurvy, beri-beri and other so-called "defici- 
ency" diseases. Milk, eggs, whole cereals, potatoes, citrus fruits, 
tomatoes (fresh and canned) and green vegetables, especially spinach 
and leafy vegetables and fresh meat are thought to contain them. 
It seems necessary to include the leaves of plants (green vegetables) 
when the seeds (cereals, grain, flour, etc.) are used. Fruit and 
vegetable acids are regulating. They maintain the reserve alka- 
linities of the blood and prevent constipation. Milk is also neces- 
sary to supplement a cereal diet as even liberal quantities of green 
vegetables cannot wholly take the place of milk. 

Summary. While we know that a man of average weight, of 
moderate activity, requires from 2500 to 3000 calories or heat units, 
31 



182 PERSONAL HYGIENE 

of food daily, it is not necessary to measure the calories, but to watch 
the scales. If your weight is in equilibrium (see weight tables and 
weight instructions) you do not have to worry about your calories. 
It is not at all likely that you need worry about your protein as that is 
present in sufficient quantity in all but very narrow diets. In fact, 
you are more likely to get too much protein than too little. If your 
diet is well diversified and includes a liberal admixture of the regulat- 
ing foods your diet is safe. That is, weight in equilibrium, protein 
taking care of itself, as a rule, excess avoided by eating meat or high 
protein food not more than once daily, and regulating elements sup- 
plied by milk, vegetables and fruit, and some raw food each day, the 
needs of the average individual are covered. 

The needs of the individual are not supplied by a meat and potato 
diet. 

Food should be thoroughly chewed or insalivated in order to insure 
good digestion and prevent overeating, especially of protein food. 
This can easily be attained, not by directing attention to chewing, 
but by tasting the food thoroughly until it slides naturally down the 
gullet into the stomach. If attention is given to tasting the food 
during the first few chews the habit will easily be formed. 

While it is not necessary to weigh your food or measure the calories 
or heat units that it furnishes, it is well to know the varying require- 
ments of different types of individuals as shown below: 

Grandparent (seventy to eighty years), 1500 to 1800. 

Father, 3000. 

Mother, 2500. 

Boy or girl of thirteen years, 3000. 

Boy or girl of nine to eleven years, 2500. 

Boy or girl of seven years, 2100. 

Boy or girl of three to four years, 1100 to 1400. 
Hard manual labor will increase requirement of father to 4000 or 
more calories. 

The calory is a unit of heat measurement and represents the amount 
of heat required to raise one kilogram of water 1° C. or 1 pound of 
water 4° F. 

MENACE OF OVERWEIGHT. 

For many years the life insurance companies have been accumulat- 
ing evidence of the unfavorable influence of overweight. There has 
lately been available from the medico-actuarial investigation of the 
experience of forty-three American life insurance companies collected 
evidence showing the influence of build on longevity. This experi- 
ence brings out the simple fact that the ideal weight after full maturity 
(about thirty-five years of age) is somewhat below the average weight. 
Light weight in early life shows a slightly unfavorable mortality, due 
to the high incidence of tuberculosis in these types. After thirty- 
five years of age light weight is an advantage rather than a detriment. 



MENACE OF OVERWEIGHT 483 

Overweight, however, shows a progressive increase in mortality with 
the increase of weight. The tables on pages 4S4 and 485 set this forth 
very clearly. The tendency to increase in weight as one grows older 
is pathological and not physiological, and should be combated. 

Benedict's laboratory experiment, referred to in a previous section, 
supports this statistical evidence, and again we have the evidence from 
many sources that restriction in diet when not carried to too great an 
extreme has resulted in improved health rather than debility. 

The public should be warned against drastic, strenuous, reduction 
methods. Barring overweight due to dropsy or to distinctly patho- 
logical conditions, which require careful medical government, over- 
weight is very easily corrected by dietetic measures alone. A great 
deal of harm has been done by physical culture enthusiasts who 
endeavor to take off weight by strenuous exercise. This is particularly 
dangerous to the middle-aged. 

Before a middle-aged individual should be subjected to anything 
more than very moderate exercise the weight should be reduced very 
materially, so that the burden may be taken from the circulation. 
It is probable that the heart muscle of the average middle-aged over- 
weight is below par. To ask such a heart to go against not only 
overweight but unusual exercise is palpably unreasonable and un- 
scientific. 

A man could sit at his desk and automatically reduce his weight 
without any exercise. He could even lie in bed and reduce his weight 
by dietetic measures and without going hungry. It is simply neces- 
sary to concentrate on the bulky foods of low fuel value. It is not 
necessary that he cut out carbohydrates and fats, but cut them down. 
A great deal of harm has been done by popular instruction based upon 
a glimmering of this truth but carried to an absurd extreme. It is 
not necessary to starve an individual or subject him to any real priva- 
tion in order to reduce the weight. Sensations of hunger can be 
appeased by bulky foods that have almost no fuel value so far as 
calories are concerned. A person can eat four or five times a day and 
lose weight. The no-luncheon practice is entirely unnecessary and 
may have the harmful effect of depriving an individual of the psychic 
value of a break in the day's work. The following dietetic principles 
afford a safe guide for the average ovens-eight individual and for the 
child: 

Suggestions for Regulation of Diets.- — Where there is a tendency to 
overweight a very careful modification of the average, normal diet is 
necessary, concentrating strongly on the bulky foods, and eating but 
lightly of the fuel foods. It is not, of course, wise to cut out entirely 
the fuel foods, such as fats, starches and sugars, but cut them down 
sufficiently to bring the weight gradually to the normal point. 

In cases of positive disease, where overweight is due to dropsy, dis- 
turbances of thyroid gland, etc., reduction should only be attempted 
under strict medical supervision. 



484 



PERSONAL HYGIENE 



INFLUENCE OF WEIGHT ON VITALITY. PERCENTAGE OF NORMAL INSUR- 
ANCE MORTALITY IN VARIOUS WEIGHT GROUPS BASED UPON THE 
REPORT OF THE xMEDICO- ACTUARIAL INVESTIGATION 1912 
COVERING AN ANALYSIS OF 744,672 MEN. 

AGES 25-29 HEIGHTS 5n 7m- 5n IOin, 



160% 



136 % 



110% ins°/108% 113 ° 

102% 101% 100% 99% 98% 98% * 






SO 40 30 20 10 S AVERAGE S 10 20 30 40 50 60 70 90 
POUNDS UNDER AV NT. iE,GHT POUNDS OVER AV. NT. 



AVERAGE NEIGHT AGE 27 5ft 8m 1S0lBS 

Fig. 77. — Average weight; age, twenty-seven years; 5 feet 8 inches; 150 pounds. 



AGES 45-49 HEIGHTS 5ft 7in-5ft IOin 



210% 



175% 



150% 



161% 



100% 



94% 91% 89% 90% 91% 94% 





50 40 30 20 10 5 AVERAGE 5 10 20 30 40 50 60 70 90 
POUNDS UNDER AV NT. NEIGHT POUNDS OVER AV NT. 



AVERAGE NEIGHT AGE 47 5 ft 8 m 160 LBS 

Fig, 78,— Average weight; age, forty-seven years; 5 feet 8 inches; 100 pounds. 



MENACE OF OVERWEIGHT 

AGES 57-59 HEIGHTS 5ft 7in-5ft 10 in 



485 



180' 




$0 40 30 20 10 5 AVERAGE 5 
.POUNDS UNDER AY. WT B * E,GHT 



10 20 30 40 SO 60 70 90 
POUNDS OVER AV NT 



AVERAGE: WEIGHT AGE 58 5FT 8 IH 563 lbs 

Fig. 79. — Average weight; ago, fifty-eight years; 5 feet 8 inches; 163 pounds. 

The percentages shown above indicate the death-rate at the designated age and 
weight as compared to the general death-rate among insured risks of the same age. For 
example, 120 per cent, means that in that particular weight group the death-rate was 
20 per cent, higher than among all risks of the same age; 94 per cent, means that the 
death-rate in that weight group was 6 per cent, lower than among all risks of that age. 
Note that in the middle-aged and elderly groups there is approximately one point higher 
death-rate for every pound of overweight; that is, 40 pounds overweight shows 39 per 
cent, extra mortality, 50 pounds overweight, 50 per cent, extra mortality, etc. Also 
note that middle-aged and elderly lightweights show a very favorable death-rate, even 
lower than among those of average weight, indicating that the man of average weight 
is either overfed or underexercised, or both. It has been possible for the Life Insurance 
Companies to select a very favorable class of lightweight but impossible, in spite of 
their care in selection, to secure a favorable type of heavyweight Apparently all heavy- 
weights, regardless of type are at a disadvantage as compared to the good lightweights. 
Lightweight, therefore, after full maturity, is an advantage unless it is due to some 
form of disease or malnutrition. "A lean horse for a long race" is a motto justified by 
Life Insurance experience. In early life the risk of overnutrition rather than under- 
nutrition should be taken, but after thirty, watch your weight and keep it at the average 
weight for that age. 



In the absence of disease it is a very simple matter to control the 
weight; that is, you must either increase your exercise to burn up 
your surplus fat, or you must reduce your fuel food so that your nor- 
mal activities will burn up the surplus fat. The most concentrated 
fuel foods are sugar and fat, such as butter and cream. Bread and 
cereals are also high in fuel value. Eat lightly of such food, and 
in order that you may not suffer from hunger or a sense of deprivation, 
eat more freely of the foods low in fuel value, such as the following: 
Fruits and vegetables, especially cabbage, lettuce, celery, spinach, 
string beans, cucumbers, carrots, tomatoes, turnips and sea-kale. 



480 



PERSONAL HYGIENE 



TABLE OF UEKJIITS AND WEIGHTS BASED UPON THE REPORT OF THE 

MKDICO-ACTUAKIAL INVESTIGATION, 1912, COVERING AN ANALYSIS 
OF 221,819 MEN AND 136,504 WOMEN. 

Table of Average Heights and Weights. — Men. 





d 


a 


d 


a 


d 


.5 


d 


ci 


d 


d 


d 

o 


a 


d 


d 


d 


d 


d 


d 


A gB, 


o 


** 


(N 


CO 


•# 


lO 


co 


i> 


00 


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o 


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co 


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^ 


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^J 


.j 


_,_; 


-tj 


_j 










































|Q 


*C 


lO 


lO 


iO 


lO 


lO 


Hi 


»o 


>o 


uO 


lO 


CO 


O 


CO 


CO 


«o 


CD 


15 


107 


109 


112 


115 


118 


122 


126 


130 


134 


138 


142 


147 


152 


157 


162 


167 


172 


177 


20 


117 


119 


122 


125 


128 


132 


136 


140 


144 


148 


152 


156 


161 


166 


171 


176 


181 


186 


25 


122 


124 


126 


129 


133 


137 


141 


145 


149 


153 


157 


162 


167 


173 


179 


184 


189 


194 


30 


126 


128 


130 


133 


136 


140 


144 


148 


152 


156 


161 


166 


172 


178 


184 


190 


196 


201 


35 


128 


130 


132 


135 


138 


142 


146 


150 


155 


160 


165 


170 


176 


182 


189 


195 


201 


207 


40 


131 


133 


135 


138 


141 


145 


149 


153 


158 


163 


168 


174 


180 


186 


193 


200 


206 


212 


45 


133 


135 


137 


140 


143 


147 


151 


155 


160 


165 


170 


176 


182 


188 


195 


202 


209 


215 


50 


134 


136 


138 


141 


144 


148 


152 


156 


161 


166 


171 


177 


183 


190 


197 


204 


211 


217 


55 


155 


137 


139 


142 


145 


149 


153 


158 


163 


168 


173 


178 


184 


191 


198 


205 


212 


219 







Table 


OF 


Ave 


RAGE 


Heights and Weights. — 


Women. 










d 


d 


_d 


a 


d 


d 


d 


d 


d 


d 


d 


d 


d 


d 


.s 


d 


d 








o 


,— 1 






















o 


,_, 




Age. 


00 


o 




1-1 


o 


rH 


CO 


CO 


■Tt< 


>o 


CD 


t^ 


00 


C5 




"- 1 


o 


-u 


-^ 


£ 


£ 


£ 


£ 


H 


£ 


£ 


£ 


+J 


£ 


-m 


-^ 


-^>" 


-^ 


£ 




•* 


■* 


■<i< 


■* 


iO 


lO 


*n 


iO 


iO 


LO 


iO 


lO 


iO 


LO 


iO 


lO 


CO 


15 


101 


103 


105 


105 


107 


109 


112 


115 118 


122 


126 


130 


134 


138 


142 


147 


152 


20 


106 


108 


110 


112 


114 


116 


119 


122 


125 


128 


132 


136 


140 


143 


147 


151 


156 


25 


109 


111 


113 


115 


117 


119 


121 


124 


128 


131 


135 


139 


143 


147 


151 


154 


158 


30 


112 


114 


116 


118 


120 


122 


124 


127 


131 


134 


138 


142 


146 


150 


154 


157 


161 


35 


115 


117 


119 


121 


123 


125 


127 


130 


134 


138 


142 


146 


150 


154 


157 


160 


163 


40 


119 


121 


123 


125 


127 


129 


132 


135 


138 


142 


146 


150 


154 


158 


161 


164 


167 


45 


122 


124 


126 


128 


130 


132 


135 


138 1 141 


145 


149 


153 


157 


161 


164 


168 


171 


50 


125 


127 


129 


131 


133 


135 


138 


141 1 144 


148 


152 


156 


161 


165 


169 


173 


176 


55 


125 


127 


129 


131 


133 


135 


138 


141 144 


148 


153 


158 


163 


167 


171 


174 


177 



The average individual will find it very difficult to reduce weight 
by exercise alone. There is not time in which to do the strenuous 
exercise necessary to keep the heavyweight in trim; hence, food 
regulation must be the main dependence in keeping the civilized man 
and woman's weight within bounds. Exercise should, however, be 
increased as weight comes off in order to prevent "flabbiness." 

The average individual requires about 2500 calories of food daily. 
From the following simple dietary an overweight who has no serious 
organic disease can bring down the diet as low as 1500 calories, forcing 
the body to contribute about 1000 calories daily of its own fat. 

Breakfast. 

Apple, small orange, or a half grapefruit, one or two eggs, thin 
toast, dry or very lightly buttered; coffee, with hot milk instead of 
cream, not more than one lump of sugar. 



Luncheon. 

Vegetable soup (no creamed soups), rye bread, bran bread or bran 
biscuit, or graham rolls — thinly buttered (one small pat only), lettuce 
and cheese salad, or lettuce and tomato, or fruit salad, French dressing. 



MENACE OF OVERWEIGHT 



487 



Dinner. 

Moderate helping of any roast of lean meat or non-fat poultry or 
fish, baked or broiled potato, any bulky vegetable (as lettuce, Swiss 
chard, parsnips, carrots, turnips, celery, oyster plant, cabbage, Brus- 
sels sprouts, tomatoes, salsify, Spanish onions, spinach), coffee, fruit 
dessert — grapefruit cocktail, oranges, or stewed fruits. 

Exercise should, of course, be followed for its other beneficial effects 
as well as for weight reduction. 

Where there is pronounced overweight it is well to weigh every 
few days in order to note the effect of the diet. It is a very simple 
matter to ease up on the fuel foods, substituting fruits and vegetables, 
and follow the effect of the diet by charting your weight on the blank 
provided for this purpose. There should be no effort at rapid reduc- 
tion, but you should try and get off a few pounds each week. 

The careful chewing, or rather tasting, of food until it naturally 
slides into the stomach will often tend to prevent overeating. 

Feeding the Children. — It is especially important at the present time 
to guard our children against insufficient nourishment. The trend 
toward simple diet and household economies must not go to the 
extreme of restricting the diet of growing boys and girls. The tissues 
of the child are undergoing rapid changes and there is a high expendi- 
ture of energy, hence the fuel requirement of the child is greater in 
proportion to weight than that of the adult. 

The average adult beyond thirty or thirty-five years requires food 
restriction and will benefit by it, but the growing child should be 
allowed to eat pretty freely, simply guiding the consumption of food 
along proper lines. 

The following table prepared from various sources by the New York 
Association for Improving the Condition of the Poor exhibits a very 
conservative estimate of the food requirements of children. 

FOOD ALLOWANCES FOR CHILDREN. 



Age, years. Boys. 

Under 2 years 900-1200 

From 2 to 3 " 1000-1300 

From 3 to 4 " 1100-1400 

From 4 to 5 " 1200-1500 

From ato 6 " 1300-1600 

From 6 to 7 " 1400-1700 

From 7 to 8 " . 1500-1800 

From 8 to 9 " ....... 1600-1900 

From 9 to 10 " 1700-2000 

From 10 to 11 " 1900-2200 

From 11 to 12 " 2100-2400 

From 12 to 13 " 2300-2700 

From 13 to 14 " . . 2500-2900 

From 14 to 15 " 2600-3100 

From 15 to 16 " . 2700-3300 

From 16 to 17 " ....... 2700-3400 



Calories per day. 



Girls. 
900-1200 
980-1280 
1060-1360 
1140-1440 
1220-1520 
1300-1600 
1380-1680 
1460-1760 
1550-1850 
1650-1950 
1750-2050 
1850-2150 
1950-2250 
2050-2350 
2150-2500 
2250-2550 



488 PERSONAL HYGIENE 

Note that the food requirement of a boy of sixteen years may 
exceed by one-third that of an ordinary sedentary business man, which 
is about 2500 calories. Children nvv(\ plenty of fuel food, cereals, 
bread and butter, milk, cheese, eggs in moderation, but not a large 
amount of meat, certainly not more than once daily. The type of 
child must be considered, but on the whole the child's demands should 
be met as regards quantity and care taken that the diet does not 
become "finicky" or too narrow. 

Fruit and green vegetables and a quart of milk daily should be 
insisted upon, and it is seldom that any undue gain in weight will be 
noticed. Such tendencies do not usually need watching until after 
age 30. 

Alcohol. — The task of the Health Officer in educating the public 
on the effects of alcohol is far more simple today than it would have 
been even ten years ago. Not only is there now available a wealth 
of laboratory evidence and statistical evidence showing the effects of 
alcohol on the human body and upon society, but the public temper 
on this matter has greatly changed within the past few years, and 
under present conditions there is a disposition to abandon the tradi- 
tional, cynical and self-indulgent attitude toward alcohol and listen to 
a presentation of the facts that science has made available. It is not 
necessary to dwell upon the association of alcoholic excess with crime 
and human misery; this is well known to every individual who has suf- 
ficient intelligence to respond to any form of education. There is no 
need to emphasize the evils of drinking to the point of intoxication. 

It is the effect of the widespread, so-called moderate use of alcohol 
that should receive the attention of the health educator. On this 
subject there are available three sources of information: (1) The 
collected experience showing the influence of alcohol upon large masses 
of lives; (2) laboratory evidence showing the effect of alcohol on the 
human organism; (3) clinical observation of the effect of alcohol in the 
apparent causation of disease and its effect as a therapeutic agent. The 
medico-actuarial investigation showing the experience of forty-three 
American life insurance companies is a particularly important source 
of evidence as to the effect of alcohol on masses of lives. The chart 
on page 489 shows in a concise form the results of this experience. 
This general experience was checked by the individual experiences of a 
number of companies, in which it was shown that everywhere high 
mortality followed the flag of alcohol. Wherever there was tempta- 
tion to alcoholic indulgence, as in occupations involving the handling 
or selling of liquors, the mortality was high, also with the increasing 
indulgence in alcohol there was shown an increased mortality. The 
experience of British life insurance companies is entirely consistent 
with that of the American companies, and there seems to be no ques- 
tion that a group of men using alcohol, all other things being equal, 
will show an increased mortality dependent upon the degree to which 
alcohol is used. Sometimes it is naively claimed that the extra mor- 
tality is not really due to the moderate use of alcohol but to the exces- 



ALCOHOL 



489 



sive and increasing use of alcohol on the part of members of the drink- 
ing group. It seems to be forgotten that increasing use of alcohol is 
one of its pathological effects quite as much as nephritis, cirrhosis of 
the liver or cerebral degeneration. The point should be made clear 
that when a man enters a drinking group he deliberately assumes an 
extra risk, just as certain buildings are subject to an extra fire risk 
because of their structure. Certain buildings, notwithstanding this 
extra risk, may stand for many years, but a group of such buildings 
will invariably show an abnormal loss. 

COMPARATIVE MORTALITY AMONG USERS OF ALCOHOL — FORTY-THREE 
AMERICAN LIFE INSURANCE COMPANIES, 1885-1908. 

DEATH RATE AMONG 
INSURED LIVES GENER- 
ALLY - MEDICO ACTUAR- 10 
IAL TABLE 



DEATH RATE AMONG 
POLICYHOLDERS USING 
2 GLASSES OF BEER, 
OR 1 GLAS8 OF WHISKEY 
DAILY 



DEATH RATE AMONG 
POLICYHOLDERS GIVING 
HISTORY OF PAST IN- 
TEMPERANCE, BUT AP- 
PARENTLY CURED 



DEATH RATE AMONG 
POLICYHOLDERS USING 
MORE THAN 2 GLASSES 
OF BEER OR 1 GLASS 
OF WHISKEY DAILY, BUT 
REGARDED AS TEMPER- 
ATE S, STANDARD RISKS 




Fig. 80 

When we turn to laboratory evidence in order to ascertain whether 
there is anything in the effect of alcohol on the human body that would 
justify the belief that the extra mortality found among large groups 
of users of alcohol is due to this disturbing effect on the human organ- 
ism, we find abundant evidence warranting this interpretation of the 
statistical ' evidence. 

The researches of Dodge and Benedict, of the Nutrition Laboratory 
of the Carnegie Institution, are particularly important not only 
because of the thoroughly unbiased scientific attitude of the inves- 
tigators but because these experiences were checked by rigid control 
methods, and the results represent the records of instruments of 
precision which cannot be questioned as to the accuracy of their 
testimony 

It is clearly shown, through Benedict's experiments, that alcohol 
belongs in the class of narcotic drugs; that even in moderate beverage 
doses it exerts a distinctly depressing influence first upon the lower 
reflex neural arcs of the spinal cord, the higher nervous mechanisms 
coming later under its influence. This is contrary to the findings of 
Kraepelin, yet it is consistent with more modern views of the func- 
tioning of the cerebrospinal system. It is not claimed by Benedict 
that the higher brain structures are not affected at the outset by 



l!t() PERSONAL HYGIENE 

moderate doses of alcohol, but it is assumed that there is in such 
tissues a power which he terms "autogenic reenf orcement " that 
enables them to resist this influence at the outset. There is some 
evidence from his experiences that as the lower reflex neural arcs pass 
from under the influence of alcohol the higher centers show its effects. 
The most important results of this investigation were the demonstra- 
tions that alcohol adds nothing to the organic efficiency of the circu- 
lation. There is an acceleration of the pulse-rate without any increase 
in its force. These researches revealed no evidence of the so-called 
stimulating effects but rather a decreased organic efficiency. 

The literature on alcohol is, of course, enormous and there is much 
valuable physiological evidence available, especially in the report 
of the British Committee to the Central Board of Liquor Control 
entitled, "Alcohol, its Action on the Human Organism." Anyone 
who assumes the responsibility of educating the public on this matter 
should cast aside tradition, especially medical tradition, and carefully 
analyze the recent statistical and physiological evidence which places 
alcohol in the class of habit-forming narcotic drugs. It should be 
impressed upon the public that the bienaise, good fellowship, the joy 
in life which so many people endeavor to seek through the short cut 
of alcohol, can be obtained through the hormones that circulate in a 
body that is exuberant with health. Such psychic value as alcohol 
may possess is usually dearly bought. Men of the w T orld who have 
used it without gross excess are frequently willing to confess that the 
"game is not worth the candle." It may properly be termed a "fake 
hormone." 

With regard to light wines and beers the same principle holds good. 
It is simply a question of degree. We certainly would not recom- 
mend the use of paregoric as a substitute for morphin. If alcohol 
is indeed a habit-forming drug its total disuse should be advised. 
People often talk very glibly about the " harmlessness " of light wines, 
forgetting that the daily use of such wines may involve a greater 
consumption of alcohol than would be the case in moderate whisky 
drinking. A high ball is not stronger than many of these wines. 

The third class of evidence, that derived from clinical observation, 
offers strong support to the conclusions derived from the more exact 
statistical and laboratory researches. The conclusions based upon 
general scattered observations are not always completely justified, 
but in the case of alcohol we may be sure that its gradual disuse by 
clinicians is scientifically sound. Even in the treatment of diabetes 
the researches of Higgins, Peabody and Fitz at the Carnegie Institu- 
tion and at the Peter Bent Brigham Hospital have shown that it does 
not possess the peculiar virtues formerly ascribed to it. It is quite 
possible that alcohol has a limited range of usefulness in medicine, in 
which case there should be no fanatical abandonment of it as a thera- 
peutic agent. Where other remedies will answer the same purpose, 
and especially w r here there is risk of its administration being followed 
by habit-forming tendencies, alcohol should be excluded. 



TOBACCO 401 

The following resolution in the House of Delegates of the American 

Medical Association shows the present temper of the medical profes- 
sion on this subject: 

"Whereas, We believe that the use of alcohol is detrimental to 
the human economy; and 

"Whereas, Its use in therapeutics as a tonic or stimulant or for food 
has no scientific value; therefore be it 

"Resolved, That the American Medical Association is opposed to 
the use of alcohol as a beverage; and be it further 

" Resolved, That the use of alcohol as a therapeutic agent should be 
further discouraged." 

There can be no question but that the former widespread use of 
alcohol as a therapeutic weapon was based upon ignorance of its 
true physiological action. 

Tobacco. — The widespread and increasing use of tobacco warrants 
the careful consideration of the public health officer. 

In its book, Health for the Soldier and Sailor, the Institute has taken 
the position set forth in the following paragraphs: 

" One hesitates to say anything against tobacco as an indulgence for 
the soldier because of the widespread campaigning for the tobacco 
fund. No one would wish to deprive the soldier of a comfort or 
solace that will help him to keep his poise or to stand the strain of 
war. But we believe that the soldier is entitled to know the danger 
of tobacco. 

Let us see what hard-headed veterans of the recent war, active 
army surgeons who have handled men at the front, have to say. Major 
Lelean, of the British Army, who has published the lectures delivered by 
him at the Royal Army Medical College recently, has this to say: 

"To take now the next item that comes in the ration list — tobacco. 
The effects of smoking on the heart and on the quality of the pulse 
are well shown by pulse-tracings. Without going into the question of 
such various objectionable ingredients in tobacco as nicotine and 
the more harmful furfural, one may say that excess of smoking, par- 
ticularly of cheap cigarettes, produces tachycardia, muscular relaxation 
and diminution of visual acuity. These conditions result in "short- 
ness of wind," which is bad for marching and produce muscular tremor 
and loss of effective sight which it need scarcely be said are worse for 
shooting. Tobacco, like alcohol, has certain compensating advan- 
tages. The mild narcotic effect of tobacco in moderation is not 
apparently attended by deleterious action on habitual smokers. See- 
ing that the allowance provides only two pipefuls a day it can do a man 
no harm to smoke one pipeful when he reaches camp and the other 
just before he turns in at night; the soothing effect is then most bene- 
ficial." 

Again he says: 

"Alcohol should be forbidden on the march; it lowers blood-pressure 
and causes rapid heat production without corresponding tissue repair. 
Smoking should be forbidden; it causes thirst, tremor and tachycardia 
(rapid heart)." 



492 PERSONAL HYGIENE 

In the London Lancet for August 18, 1917, there are presented the 
results of experiments by Captain John Parkinson, of the Royal Army 
Medical Corps, and Dr. Ililmer Koefod, of Harvard, U. S. A., on 
"The Immediate Effect of Cigarette Smoking on Healthy Men and 
on Cases of Soldier's Heart. 1 ' 

"In the present war heart disturbances characterized by breathless- 
ness after exertion, pain in the chest, rapid, irregular heart action, 
giddiness and exhaustion are quite common. 

"In some cases valvular disease of the heart (V. D. H.) is found 
and the soldier is discharged, but in others no organic defect can be 
discovered, and these are classified in the Army Medical Service as 
D. A. H. (disordered action of the heart) and are termed "soldier's 
heart." The experimenters summarize their findings as follows: 

"These observations show that in health the smoking of a single 
cigarette by a habitual smoker usually raises the pulse-rate and blood- 
pressure perceptibly and these effects are a little more pronounced in 
cases of ' soldier's heart.' Moreover, the smoking of a few cigarettes 
can render healthy men more breathless on exertion, and manifestly 
does so in a large proportion of these patients. 

"Excessive cigarette-smoking is not the essential cause in most cases 
of 'soldier's heart,' but, in our opinion, it is an important contributory 
factor in the breathlessness and precordial pain of many of them." 

The results of these experiments are exactly in line with those 
reported by Dr. George J. Fisher, physical director of the International 
Committee of the Young Men's Christian Association in his interesting 
book The Physical Effects of Smoking. 

A number of careful experiments were made on a group of fifteen 
young subjects, physical directors in normal condition of health, and 
engaged in vigorous exercise daily. Seven were non-smokers and eight 
classed as "moderate smokers." The experiment covered investiga- 
tion of the heart-rate after exercise, the precision of neuro-muscular 
movement and accuracy in baseball-pitching. 

The results of these various experiments are summarized as follows: 

1 . Smokers have a normal heart-rate higher than non-smokers. 

2. Smoking causes a delay in the return of the heart-rate to normal 
after exercise. As evidenced in this study, this delay is 7.9 minutes for 
non-smokers and 6.8 minutes for smokers. 

3. Equilibrium of heart-rate is not established in habitual smokers, 
i. e., the body does not become accustomed to smoking, for there is 
but a slight difference in the length of time of the return of the heart- 
rate to normal between smokers and non-smokers. 

4. To the writer the most important conclusion as shown by the 
work is that: 

(a) In 74 tests out of 118 smoking tests, or 62.72 per cent., the 
heart-rate was increased and did not return to normal at the fifteenth 
minute. In 72 out of 74 tests without smoking, 9'i per cent, of all 
the tests taken, the heart-rate returned to normal in less than fifteen 
minutes, the average time being only five minutes. 



TOBACCO 493 

(b) The average heart-rate at the fifteenth minute was 11.2 beats 
greater than the average normal heart-rate. 

These experiments are exceedingly convincing. They are also 
exceedingly original. They show that the smoker apparently does 
not become habituated to the use of tobacco, that exercise disturbs 
him more than the non-smoker, that physical work causes more of a 
disturbance in organic function in those who smoke than in those 
who do not. Apparently, therefore, athletic coaches have been wise 
in asking their athletes to give up smoking when training. We would 
imagine also that the non-smoker, other things being equal, would 
make the better workman, for he can work with less disturbance : 

1. All smokers showed a loss in physical precision immediately 
after smoking. 

2. Five of the seven smokers showed improvement during the 
interval when not smoking. 

3. Smokers showed a greater lack of neuro-muscular control after 
exercise than non-smokers. 

4. Xon-smokers showed slight gain in precision during smoking tests. 
This, in the mind of the writer, is probably due to greater experience 
with the apparatus. 

6. All non-smokers showed improvement in neuro-muscular control 
after exercise. 

7. Some of the subjects in both classes were affected more than 
others. This was more pronounced in the tests taken with non- 
smokers. 

8. General effect of smoking on the non-smokers also produced 
other serious results, in some cases physical discomfort. 

In test A, during which one cigar was smoked, the smokers showed 
a loss of 11 per cent, in accuracy when pitching a baseball after smoking. 

In test A, during which one cigar was smoked, the non-smokers 
showed a loss of 13 per cent, in accuracy when pitching a baseball at 
a target after smoking. 

The non-smokers show an increase of 2 per cent, over the smokers 
in loss of accuracy after smoking. 

The average loss in accuracy during test A for both smokers and 
non-smokers is 12 per cent, after smoking. 

In test B, during which two cigars were smoked, the smokers showed 
a loss of 11 per cent, in accuracy when pitching a baseball at a target 
after smoking. 

The non-smokers in test B showed a loss of 18 per cent, in accuracy 
when pitching after smoking. 

The non-smokers show an increase of 7 per cent, over the smokers 
in loss of accuracy after smoking. 

The average loss in accuracy after smoking during test B, for both 
smokers and non-smokers, is 14.5 per cent. 

In test C, during which no cigars were smoked, the smokers showed 
an increase in accuracy of 9 per cent, after a delay of thirty minutes, 
equal to the time taken in smoking a cigar. 



l!) I PERSONAL HYGIENE 

In test C the non-smokers showed an increase in pitching a base- 
ball accurately without smoking of 10 per cent. 

The non-smokers showed a gain of 1 per cent, over the smokers 
in accuracy of pitching. 

The average gain in accuracy of pitching during test C for both 
non-smokers and smokers is 9.5 per cent. 

1 . The foregoing experiments have proved conclusively that smok- 
ing does actually reduce a man's accuracy in pitching a baseball. 

2. The smoking of a single cigar will affect a man's accuracy in 
pitching and two cigars increase this effect. 

3. In tests during which there was no smoking the men improved in 
accuracy of pitching. 

From this we see that the heavy use of tobacco (and there is grave 
danger of an exceedingly heavy use if the soldier is not warned) is a 
serious menace to the soldier and that even the moderate use is not 
without danger to his health and to his efficiency in marksmanship, 
bomb-throwing and other work requiring team work by brain and 
muscle. Naturally, if the solace of tobacco will keep the soldier 
from going insane or losing his control in short periods of strain it 
might prove of value as a veritable medicine for some, but the average 
soldier should not have tobacco showered upon him without a word as 
to its possible harmful effect upon the heart." 

It is to be hoped that thoroughgoing laboratory investigations 
similar to those carried on by Benedict at the nutrition laboratory on 
the effects of alcohol will, in the near future, be undertaken with 
regard to tobacco, also that the statistical evidence will in due course 
be available from life insurance companies and other sources. 

In the interval of such research those upon whom the responsibility 
falls for guiding the public are perfectly justified in taking the posi- 
tion that tobacco is a narcotic poison, that even its moderate use, as 
in the case of alcohol, is attended by the danger of increasing use, 
that it is not consistent with wise counsel to the public to encourage 
even the moderate use of such a drug, that the public should be encour- 
aged to maintain a standard of health that is independent of these 
narcotic resources and attempted short cuts from life strain. 

The average individual who first uses tobacco usually experiences 
profound poisonous effects. It is true that the nervous system subse- 
quently becomes adjusted to this indulgence, but this is the case 
with all narcotics, even morphin. No physiologist would claim that 
the adjustment of the organism to large doses of morphin represents 
a favorable physiological condition. The same principle holds true 
with regard to tobacco as with any other indulgence. It is sought as 
a substitute for hormones, as an escape from life strain; this support 
and this escape should be sought in constructive ways and not through 
the destructive influence of drugs. 

The most effective stand for the health educator to take is one of 
frank and fearless presentation of the truth. It is not necessary to 
preach against the use of tobacco but simply state the facts as to its 
possible injury so that those who use it may clearly understand the 



TOBACCO 



495 



risk they are assuming. The health educator who shrinks from 
disturbing a pet indulgence or from arousing popular prejudice is 
recreant to his task. The public should have the facts without 
regard to where they cut and the responsibility is then on the public 
for persistent violations of health laws. 

One drop of nicotin on the unshaved skin of a rabbit has been 
known to cause death. There is probably enough nicotin in the 
average cigar to kill a man if he got the full dose. Nicotin in the 
rapidity of its fatal effects resembles prussic acid. The widespread 
toying with such a powerful poison is not a laughing matter; it is 
entirely worthy of careful attention of the public health officer, espe- 
cially as the tide rises against alcoholic indulgence. It may be that 
tobacco indulgence may arise as a substitution factor if its possible 
harmful effects are not more clear. As in the case of alcohol, most 
men who smoke at all smoke too much, that is, smoke to a degree, 
which, in the long run, will probably prove distinctly harmful and life- 
shortening. 

The following are extracts from a health letter approved by the 
Hygiene Reference Board of the Life Extension Institute. 

What It Costs to Smoke Tobacco. — The smoke bill, like the alcohol 
bill, grows apace in this country. In 1880 the annual per capita con- 
sumption of tobacco in the United States was about 5 pounds, but 
in 1914 it had risen to more than 7 pounds. In the United Kingdom 
the per capita consumption is about 2 pounds, and there has been no 
material increase in recent years. 

The cigarette bill, in particular, has grown enormously, having more 
than doubled in five years, while there has been a slight increase in 
the consumption of cigars, smoking tobacco, chewing tobacco and snuff, 
as shown in the following table: 

REPORT OF THE COMMISSIONER OF INTERNAL REVENUE (WITH- 
DRAWALS TAX PAID FOR CONSUMPTION OF MANUFACTURED 
TOBACCO PRODUCTS DURING THE PAST FIVE YEARS). 









Tobacco, 




Fiscal year. 


Cigars. 


Cigarettes. 


chewing and 
smoking. 


Snuff. 




Number. 


Number. 


Pounds. 


Pounds. 


1913 


8,732,815,703 


14,294,895,471 


404,362,620 


33,209,468 


1914 


8,707,625,230 


16,427,086 016 


412,505,213 


32,766,74] 


1915 


8,030,385,603 


16,756,179,973 


402,474,245 


29,839,074 


1916 


8,337,720,530 


21,087,757,078 


417,235,928 


33,170,680 


1917 


9,216,901,113 


30,529,198,538 


445,763,206 


35,377,751 


Total . . . 


43,025,448,179 


99,095,112,076 


2,082,341,212 


164,363,714 



The annual expenditure for tobacco in this country is at least 
$1,200,000,000, a huge sum to go up in smoke. 

Effects on Animals and Man. — Nicotin at first slows the heart and 
increases the blood-pressure, subsequently the blood-pressure is 
lowered and the heart action becomes rapid. The effect on the brain 
is essentially narcotic, or depressing. Those whose thoughts flow more 
readily under the use of tobacco are simply in the same case with any 



496 PERSONAL HYGIENE 

other habitue whose thoughts cannot flow readily except under the 
accustomed indulgence. That a sound and healthy man, who has 
never been accustomed to the use of tobacco, can do better mental or 
physical work with tobacco than without it has never been shown. 
Indeed, experiments show the contrary. 

Some of the unfavorable effects that have been noted by physicians 
are as follows: 

Heart and circulation: Disturbance of the blood-pressure, rapid heart 
action, shortness of breath, palpitation of the heart, pain in the region 
of the heart. 

Acid dyspepsia, insomnia, catarrhal conditions of the nose, throat 
and ear, and even blindness, have followed the excessive use of tobacco. 

In a majority of instances, tobacco is evidently used for its drug 
effect. Snuff-taking and the chewing and smoking of tobacco are all 
practised largely for their narcotic influence. Tobacco deprived of 
nicotin has never been popular, notwithstanding the efforts of the 
French and Austrian governments to make it so. 

Its narcotic influence, however, is so slight, as compared to opium, 
alcohol, cocaine, etc., that the habit is less demoralizing than other 
narcotic habits, and can usually be readily broken off. As smoking 
is often practised by men of high moral character, there is practically 
no moral restraint upon the smoker as a check to increasing indulgence. 

What Can Be Said in Favor of Tobacco. — A careful examination of 
the evidence does not show that tobacco will do anything for the 
steady support and upbuilding of health. Such solace and surcease 
as it may bring would better be secured through healthful forms of 
recreation that will cost nothing in physical deterioration and cost even 
less in actual money. 

The mistake that men make is in tacking alcohol and tobacco on to 
nearly even' form of game or recreation that they follow, instead of 
seeing what they can get out of the game itself. The sums that 
many men with small incomes spend on tobacco would, in the course 
of a year, pay for many wholesome recreations which are considered 
beyond the means of the average w T orker. 

CARE OF THE TEETH, TONSILS, ETC., TO AVOID OR REMOVE 

FOCAL INFECTION. 

The work of Billings, Rosenow, and the Mayos has done much to 
uncover the importance of microorganisms as causative factors in 
chronic organic disease as well as in acute surgical affections. 

Probably nothing would contribute more effectually to put out of 
business the various pseudoscientific cults and u isms" than a thorough 
dissemination of knowledge on this subject. With the definite causes 
of disease revealed the mystery monger is hard-pressed to justify his 
" laying on of hands" and his relation of all the ills that flesh is heir to 
to some mysterious cause which only he or his cult is competent to 
remove. The man with a magic liniment is made ridiculous when the 
true cause of rheumatism is revealed. Even a comparatively harmless 
and sometimes helpful physical culturist must take heed that he is 



CARE OF TEETH AND TONSILS TO AVOID INFECTION 497 

not engaged in a sisyphean task of trying to "build up" by strenuous 
exercise a dangerously infected body. 

As various diseases are placed in the group of conditions which may 
be caused by focal infection we come closer to the realization of the 
fact emphasized in previous chapters, that disease is not an entity 
and that among the definite concrete causes of physical degeneration 
or impairment bacterial infection is the most important. A due sense 
of proportion must, of course, be observed in this matter. Various 
factors other than infection may contribute to lower the bodily resistance, 
and we may have such conditions as pyorrhea as a result rather than 
a cause of ill health. Such cases call for sound judgment in their 
government. Every phase of the individual activities, diet and 
exercise should be considered while at the same time effort should be 
made thoroughly to correct the mouth conditions by surgical and 
local means so far as this may be possible. 

People vary in their reaction to these focal infections. On the 
other hand the focal infections vary widely in their virulence and in 
their selective location. This selective localization of infection is 
a striking illustration of the complex and insidious struggle that is 
continually going on beneath the surface. 

Focal infection or the point at which microorganisms are collected 
ready to invade the body and localize in some region where resistance 
is lowered may be an important factor in causing the following 
diseases: Acute rheumatism, chronic rheumatism (so-called arthritis 
deformans), ulcer of the stomach, duodenal ulcer, functional and 
organic heart disease, acute and chronic kidney disease, diabetes 
and diseases of the pancreas, infection of the cavities of the face 
and head, brain abscess, anemia, Hodgkin's disease, neuritis, arterial 
changes. 

It is well to remember that we have not solved the problem of 
mouth infection when we bring about the effectual use of a tooth- 
brush. There are people who have faithfully and properly used their 
tooth-brushes for many years and yet have not escaped infection 
because of some other fault in hygiene that has lowered their resist- 
ance. The preservation of the teeth and their protection from caries 
is, of course, a matter of immense importance in preventing mouth 
infection. It is probable that future generations will have less trouble 
in this regard than adults of the present day who have been victims 
of well-intentioned and highly skilled workers in dentistry who have 
unwittingly sealed infection into many a tooth which might better 
have been removed. Even yet tradition still sways the dental pro- 
fession to some extent and teeth that are a constant menace to the 
body are nursed and treated at some risk to the individual. 

In the examinations of the Institute it has been our experience 
that few mouths are free from root abscesses. In a series of 1800 
.r-ray cases 62 per cent, of the individuals examined showed root 
infection. No doubt in some cases the infection is non-virulent, 
but there is always a presumption that there is at least a slowly 
operating unfavorable influence from such a focus, 
32 



498 PERSONAL HYGIENE 

Arteries do not harden and tissues and cells change into the final 
condition of senility without definite cause and these infections must 
all have their contributory influence. Hence, the fact that a patient 
does not suffer from rheumatism and is free from other prominent 
symptoms of focal infection is no valid reason for regarding a root 
abscess as of no importance. 

A very competent dentist recently expressed some skepticism as 
to the menace of these abscesses which had existed for many years, 
stating that he had known many people who apparently had suffered no 
ill-effects from them. I asked him if these people were not growing 
old gradually and showing signs of physical failure. Always this basic 
fact seems to be ignored by people who demur to the indictment that 
is brought by hygienists against various unhygienic practices or 
preventable physical defects. The fact that a man is not ill in the 
ordinary sense of the word is entirely satisfying to such people; their 
imaginations do not rise to the point of visualizing a retardation of 
the process of aging or of the attainment of a late maturity that is 
free from the restrictions, handicaps and minor miseries that are the 
common lot. And as an answer to all such people we have the incon- 
trovertible fact of death coming to all who do not die by accident, as 
a palpably pathological state, however it may be masked by the 
euphemism "senility" or "natural decay." 

This great menace of focal infection is the most powerful argument 
for periodic physical examination. As a primary step in personal 
hygiene the body should be thoroughly searched for such infection. 
It staggers the imagination to reflect upon how much misery and 
premature death would be prevented if every individual in the com- 
munity would have a complete x-ray of the jaw and a thorough exam- 
ination of the head cavities. Septic tonsils should be sought for, also 
the intestinal tract should be investigated as a possible source of 
subinfection. There is excellent scientific support to the theory that 
bacteria can travel directly through the tissues and do not have to 
proceed through the lymphatics and blood stream. 

The health officer should impress upon the people that just as it 
is necessary to search the community for centers of infection, for 
sources of water pollution, for sources of milk infection, etc., so is it 
important to search the body for centers of infection, for structural 
weaknesses, for the manifestations of faulty hygiene. It should, 
however, be impressed upon the people that a life must be considered 
as a whole and that there is required not merely a physical examina- 
tion of the body, but also a consideration of the psychic relationships, 
the environment, the mental hygiene, the activities of the individual, 
his family and personal history. All these factors together with the 
present physical condition should be considered and the needs of the 
individual interpreted by a study of the complete evidence. The ideal 
that we should struggle for is the perfect adjustment of the individual 
to his environment. This, of course, can never be attained but we 
should work toward it rather than rest content with the limitations 
imposed by tradition. 



CHAPTER XX. 

ADDITIONAL PRACTICAL POINTS IN PERSONAL 
HYGIENE. 

By ARTHUR R. GUERARD, M.D. 

Air is the first necessity of life. The air supply of the individual 
is of as much importance as his water or food supply, and good ven- 
tilation in the home thus becomes the first rule of personal hygiene. 
(See Chapter VII for methods.) 

Living and working rooms should be ventilated both before occu- 
pancy and while occupied. The mere construction of the proper 
kinds of buildings, with ideal window-space and ventilating apparatus, 
does not insure ventilation unless these are actually used. 

The most important features of ventilation are motion, coolness 
and the proper degree of humidity and freshness. 

Persons who are unaccustomed to ventilation, and consequently 
oversensitive to drafts, should avoid exposure while changing their 
habits; and it is never advisable that a person in a perspiration should 
sit in a strong draft. But after even a few days of habitual enjoy- 
ment of air in motion, with gradual exposure, the likelihood of colds 
is greatly diminished; and persons who continue to take advantage of 
moving air soon become almost immune to colds. 

The germs are almost always present in the nose and throat. The 
usual cold is produced by the exposure to a draft plus the presence of 
germs and a lowered resistance of the body. Sailors who are con- 
stantly exposed to all kinds of rough weather never take cold until 
they come ashore. 

The importance of coolness is almost as little appreciated as the 
importance of motion. Heat is depressing. It lessens both mental and 
muscular efficiency. The temperature of living and work rooms should 
not be above 70° F., and for people who have not already lost largely 
in vigor by living in overheated rooms, and for those who are actively 
employed, a temperature of 5° to 10° lower is preferable. 

An accumulation of house dust should be avoided. The dust should 
be removed, not by a feather duster which scatters the dust into 
the air, but by a damp or oiled cloth. Dust-catching furniture and 
hangings of plush, lace, etc., are not hygienic. A carpet-sweeper is 
more hygienic than a broom, and a vacuum-cleaner is better than a 
carpet-sweeper; hence, removable floor rugs are hygienically preferable 
to fixed carpets. 

The air that is breathed should be sunlit when possible. Most 



500 ADDITIONAL PRACTICAL POINTS IN PERSONAL HYGIENE 

bacteria do not long survive when exposed to the direct rays of the 
sun. Lack of light also has an indirect effect in favoring uncleanliness 
and in being usually accompanied by faulty ventilation. 

Outdoor Living. — While the proper ventilation of houses is necessary 
to health, this alone cannot be depended upon. Outdoor life is an 
essential part of personal hygiene. The best ventilated house is not 
as good as outdoor air. Those who spend much of their lives in the 
open enjoy the best health and live longest. 

Climate, of itself, is a secondary consideration. Not everyone can 
select the finest climate in the world to live in, but the main advantages 
of fresh air can be had in almost any locality. Even in a city outdoor 
air is, under ordinary circumstances, wholesome and invigorating. 

The common prejudice against damp air greatly exaggerates its 
evils. While moderate dryness of air is advantageous, it is generally 
more healthy to live in damp, even foggy air out of doors, than to 
live shut up indoors. 

Pupils in outdoor and open-window schools are not only kept more 
healthy, but learn more quickly than those in ordinary schools. Tuber- 
culous children even in an outdoor school are found to make more 
rapid progress in their studies than normal children in a badly venti- 
lated school. 

Health officers should instruct the public in this matter, and parents 
should require ample fresh air for their children when at school; and 
they should also insist on outdoor playgrounds. 

Whenever practicable, outdoor recreation is preferable for all per- 
sons to indoor recreation. And for the same reason outdoor occupa- 
tions, when possible, are preferable to indoor occupations, such as 
working on a farm rather than in a factory. 

Outdoor Sleeping. — Unfortunately most people cannot live out 
of doors, and many are so situated that they cannot even secure 
proper ventilation indoors. But almost everyone can control his own 
air supply at night when sleeping. As about one-third of life is spent 
in bed, and a large majority of persons live confined lives during the 
day, it is important for most people to obtain sufficient fresh air at 
night. 

It is the universal testimony of those who have slept out of doors 
that the best-ventilated sleeping room is inferior in healthfulness to an 
outdoor sleeping porch, or window tent. 

For generations outdoor sleeping has occasionally been used as a 
health measure in certain favorable climates. But only in the last 
two decades has it been used in ordinary climates and all the year 
round. This practice has now been introduced for the treatment not 
only of tuberculosis but also of nervous troubles and of other diseases, 
including pneumonia. Lately the value of outdoor sleeping for well 
persons of all classes, infants and children as well as adults, has come 
to be recognized. 

Outdoor sleeping increases the power of resistance to disease, and 
greatly promotes physical health and efficiency. 



1 



DEEP BREATHING 501 

Many persons arc still deterred from sleeping out by a mistaken 
fear of night air and of the malaria which they imagine the night air 
may bring. Today we know that malaria is communicated by the 
bite of the anopheles mosquito and has nothing to do with the air. 
When necessary the mosquito can be shut out by screens which do 
not exclude the night air. The truth is that night air, especially in 
cities, is distinctly purer than day air on account of the fact that 
there is much less traffic at night to stir up dust. 

It is important, in any sleeping balcony, to be protected from the 
wind by a sash on one or two or — in very windy places — three sides. 

A roll curtain (preferably rolling from the bottom) can be arranged 
on the open side or sides, to be used in case of storms only. In cold 
weather a thick mattress, or two mattresses, should be used. The 
body should be warmly clad, and the head and neck protected by a 
warm cap or helmet or hood. To prevent the entrance of cold air 
under the bedclothes, one or more blankets should be extended at 
least two feet beyond the head, with a central slit for the head. Early 
awaking by the light may, if necessary, be prevented by touching the 
eyelids with burnt cork, or by bandaging the eyes with a black cloth. 
Sheets should be well warmed in the winter time before being used by 
means of a hot-water bag, flatiron or soapstone. Blankets next to 
the skin are not hygienic. 

When a sleeping porch is not available, an inward window tent 
can always be had which puts the sleeper practically out of doors, 
and at the same time cuts off his tent from the rest of the room. 

An outdoor tent must be kept well opened if it is not to fail of its 
purpose. The canvas, of which tents are made, is of tightly woven 
fabric and impervious to air and thus affords no ventilation unless 
sufficiently open. 

Deep Breathing. — Deep breathing is of great benefit to persons 
who are shut in most of the day. If they are taught how to breathe 
deeply and w T ill seize the opportunity, whenever it offers, to step out of 
doors and take a dozen deep breaths, they can partly compensate for 
the evils of indoor living. 

In ordinary breathing only about 10 per cent, of the lung contents 
is changed at each breath. In deep breathing a much larger per- 
centage is changed, the whole lung is forced into action, and the circu- 
lation of the blood in the abdomen is more efficiently maintained, thus 
equalizing the circulation throughout the body. The blood-pressure 
is also favorably influenced, especially when increased pressure is due 
to nervous or emotional causes. 

Breathing exercises should be deep, slow, rhythmic and through 
the nose, not through the mouth. Muscular exercises stimulate deep 
breathing, and in general the two should go together. But deep 
breathing by itself is also beneficial if very slow. Forced rapid breath- 
ing is comparatively useless, and indeed may be positively harmful. 
Oxygen is absorbed only according to the demand for it in the body 
and not according to the supply. 



502 ADDITIONAL PRACTICAL POINTS IN PERSONAL HYGIENE 

Cleanliness. Cleanliness is to the body what oil is to the machine; 
it preserves from rust. The best-kept machines last longest. It need 
not be proved that uncleanliness must invariably breed disease. 
Bathing is necessary for cleanliness. The hands, face and finger- 
nails should be kept clean, especially before meals. Any cut or 
abrasion of the skin or mucous membrane may allow bacteria to enter 
when the spot is dirty or is touched by dirty hands. 

The need of cleanliness is particularly great for those who work 
in factories, mines and other places where dirt is likely to be carried 
to the mouth by the hands. The larger majority of the infections 
get a foothold in this way. 

A person who does not bathe daily is almost certain to carry on 
his skin some perspiration which, while he may be unaware of it, 
gives forth an offensive odor that may be noticed by others. Perspira- 
tion prior to bathing promotes cleanliness. The most beneficial 
method of securing perspiration is by vigorous exercise; but when a 
person cannot or will not take exercise, perspiration can be induced by 
hot baths. Such extreme measures ought not, however, to be resorted 
to too often. How often will depend on corpulence and other cir- 
cumstances of each individual. Sweating may be overdone, and should 
never be pushed to the extent of exhaustion. 

Some of the most serious and widespread infections are those from 
the venereal diseases, with a whole train of terrible consequences, 
such as blindness, joint diseases with heart complications, peritonitis, 
paralysis and insanity. They can only be avoided by living a life 
of hygienic cleanliness, not only of body but mind. From even the 
narrowest interpretation of personal hygiene, a decent life is necessary 
for the maintenance of health. This is a subject about which most 
people are extremly ignorant and need instruction. 

Care of the Skin. — The skin is not merely a covering and protection 
for bone, muscle and other tissue against cold and infection, but it is 
a very important organ in close relationship with the internal organs. 
It is a part of the heat-regulating machinery of the body ; and it is the 
organ of secretion and excretion, though it is of very little importance 
as an organ for the removal of waste products. Its main function is 
to regulate the heat of the body. Care of the skin, therefore, is essen- 
tial for health, not only for cleanliness but to train it as an organ to do 
its main work, that of heat regulation. In his artificial mode of living, 
man has become an indoor animal and he has further modified the 
condition of his skin by wearing clothing often of a closely woven 
material which shuts the skin off from the light and air and protects it 
so effectively from the changes of temperature that the original vigor 
of the skin is lost. Fully to restore this primitive vigor is not possible 
under civilized conditions, but much may be done by proper exercise 
and skin training, by judicious exposure to light and air and graduated 
cold bathing, and by wearing suitable clothing. 

Bathing. — 1. Air Baths. — An air bath promotes a healthy skin and 
aids it in the performance of its normal functions. Not every one can 



BATHING 503 

visit air-bath establishments or outdoor gymnasia or take the modern 
nude cure; but any one can spend at least a little time in a state of 
nature at home. The whole body should be exposed to light and air 
for a certain time each day, while at the toilet or before retiring, 
care being taken not to let the body become chilled. This applies to 
persons free from organic disease whose bloodvessels and nervous 
system can respond to such measures. The sensitive skin that cannot 
stand a draft is thus brought nearer to the primitive resistant condition. 

2. Cold Baths. — This is still further obtained by the tub bath for 
the purpose of skin training, entirely apart from the cleansing of the 
skin. The cold bath habit is common among the better classes in 
England and America and ruddiness and fine complexions are in 
no small part due to the custom. The daily cold bath should be 
taken by everyone having the facilities and able to secure the after- 
glow or reaction which should follow if the bath agrees. The cold 
shower or sponge bath can be employed when the tub bath is not 
feasible. For many persons unable to take a cold bath without feel- 
ing chilly afterward, and for children, the use of hot water to sit or 
stand in while taking a cold shower or sponging will often prevent 
undue shock. Standing in about a foot of hot water the body may be 
briskly rubbed with a wash cloth wrung out of water at about 80° F. 
and reduced day by day until it is down to 50° F. Following this 
the cold douche shower or effusion may be taken, beginning at 90° F. 
until 50° F. is reached, or until an agreeable reaction ceases to follow. 

Persons unaccustomed to cold baths should begin to take them in 
summer and so continue them throughout the year. They are very 
valuable for many of those who think them impossible ; namely, those 
who take cold readily and frequently, those below par and needing 
tone. The cold water should be applied to the skin only for a minute 
or two and followed by brisk rubbing with a coarse towel. For young 
children, old persons unaccustomed to cold water, and those with 
weak hearts or kidney disease, or for women during menstruation, or 
in the later months of pregnancy, cold baths are inadvisable. Also 
cold baths are harmful to persons fatigued with muscular exertion and 
to those excessively hot, but may be taken by healthy persons when 
warm with moderate exercise. Cold baths should be taken before 
breakfast or at least three hours after eating and in a warm room. 

3. Warm Baths. — Cleanliness requires that a warm bath should be 
taken by the ordinary person at least twice a week. Pure soap and 
warm water form an emulsion with the fatty matters obstructing 
fat glands and hair follicles and prevent the clogging of these so-called 
"pores," which so often permits an infection to recur and results in 
acne and other skin eruptions. 

The tepid or neutral bath (80° to 90° F.) has no special effect apart 
from cleansing, although it is restful. It is suitable for invalids, the 
elderly, convalescents, and those who do not react well to cold baths. 
It may be taken at any time of day, but preferably before meals or 
at bedtime. 



504 ADDITIONAL PRACTICAL POINTS IN PERSONAL HYGIENE 

The warm bath (90° to 100° F.) is the appropriate one for infants, 
and to prevent sleeplessness in adults when taken just before bedtime. 
It is also excellent after severe muscular exercise to relieve soreness 
and stiffness of joints and muscles. It should not be employed until 
two or three hours after meals. It is unwise to venture into the cold 
air immediately after a warm bath. 

The hot bath (105° to 110° F.) is unsuitable, except for the strong, 
as it is depressing to the circulation. It should only be used at night 
or when the bather is to stay in a -warm atmosphere, and not after 
meals. At bedtime the hot bath may, however, cause sleeplessness 
unless a cold cloth is kept on the head during the bath. The hot 
bath is very valuable in preventing colds after exposure and chilling 
and to produce sweating in many disorders in which it is necessary to 
open the pores of the skin. 

4. Turkish Baths. — The Turkish bath consists of a hot air bath 
(120° to 170° F.) for ten to thirty minutes, followed by a hot shower 
bath, then shampooing and general massage in moist air (100° to 110° 
F.), and finally by a warm show 7 er bath, changing to cold, with thorough 
rubbing and drying and rest for half an hour in blankets. 

In the Russian bath moist instead of dry air is used in the beginning, 
which is more oppressive. Turkish and Russian baths are unsafe 
for persons with weak hearts or who are very fat. They are useful 
in the first stages of a cold, but the patient must not be exposed to 
the cold air afterward or there will be decided danger of bronchitis 
and other pulmonary troubles. Muscular or joint stiffness, following 
severe physical exertion and some forms of rheumatism, are much 
benefited by the Turkish bath. 

5. Outdoor Bathing. — The pure air, the exercise, the sunlight, the 
stimulating effect of the waves and salt (in sea water), and, in addition, 
the pleasure, make this form of cold bath (usually from 60° to 75° F.) 
particularly healthy. It is, however, often grossly abused. The 
effect of remaining in cold water for a considerable time causes an 
immense loss of body heat and consequent drain upon the vitality. 
Sea bathing is exhausting to those who stay in the water too long. 
This applies especially to children who alternately play out of the 
water while clothed in wet bathing suits and occasionally return into 
the water, or wade with bare feet in cold w r ater while their heads are 
exposed to the burning sun — a combination that favors sunstroke. 
Fat people can often stay in cold water for some time without ill 
effect. The length of time which it is safe to stay in cold water 
depends entirely on its temperature — anywhere from two to twenty 
minutes. The stay should never be so long as to cause blueness of 
the lips and fingers, chattering teeth or chilliness afterward. The 
head should always be w T et before plunging into cold w r ater either by 
diving or dipping the head. Those accustomed to cold water may 
bathe before breakfast to advantage; others should w r ait until three 
hours after meals. Sudden and unexpected deaths among bathers 
and swimmers are frequently due to either special weakness of the 



CARE OF THE SCALP 505 

heart or overexertion. The dangers of "cramps" are probably much 
exaggerated. Those who are subject to fainting, palpitation or known 
disturbance of the heart, and the elderly not habituated to cold water, 
should refrain from bathing out of doors, as also those likely to suffer 
from cold indoor bathing, as stated. 

Care of the Complexion. — There is an unfounded fear of the effect 
of soap on the skin of the face and scalp. As an ordinary hygienic 
measure the face should be washed once a day with warm water and 
a good quality of soap. Care should be taken not to irritate the skin 
by too vigorous rubbing and the soap should be carefully rinsed off and 
the skin thoroughly dried after final bathing in cold water. The face 
and hands should not, ordinarily, be too frequently washed during the 
day in cold weather and care should be taken always to thoroughly 
dry the skin and avoid chapping. 

About once a week it may be well to rub cold cream on the face 
very lightly and then carefully rub it off with a soft towel, subsequently 
washing the face with hot water and soap and finally washing with cold 
water. All such directions are subject to personal peculiarities and 
diseased conditions where soap and water may prove irritating, but 
for the average skin they hold good. 

Pimples showing pus should be punctured with a sterilized needle, 
and the parts afterward bathed with saturated boric acid solution 
and very hot, moist cloths applied. Vigorous squeezing of blind 
pimples should be avoided. Blackheads may be extracted with a 
comedo extractor similar to a watch key, followed by bathing and 
treatment as above. Steaming the face is sometimes of value. 

Care of the Scalp. — The scalp being a part of the skin, what has been 
said as to cleanliness applies with double force because the hairy cover- 
ing invites the collection of dirt. Shampooing often enough to keep 
the scalp and hair clean is a hygiene measure to be encouraged, but 
very frequent washing is harmful. Temporary dryness of the hair 
may result which can be relieved by rubbing the hair and scalp with 
alcohol in which there is dissolved three to six teaspoonfuls of castor 
oil to the pint; it has also a certain antiseptic value. Too frequent 
washing of the scalp keeps the sebaceous glands open and tends to 
increase the flow of oily secretion (sebum). Oil is not needed to 
nourish the hair; the hair as it emerges from the skin is dead tissue 
and cannot be nourished. The fats poured on it from the sebaceous 
glands merely keep it glossy. Shampooing with tar soap or sulphur 
soap is a good measure for dandruff. The disease of which this 
common affection is the sign is thought to be caused by germs and 
sometimes, when excessive, may result in baldness. Baldness may 
also be due to wearing close-fitting, ill- ventilated hats and by deficient 
blood supply to the hair, as well as by excessive dandruff. Gray 
hair is caused by loss of pigment and the presence of air bubbles that 
occupy spaces in the hair. There is no cure; the best preventive is 
general care of the scalp as above outlined and general hygiene. 
Heredity is a factor in both baldness and gray hair. 



506 ADDITIONAL PRACTICAL POINTS ix PERSONAL HYGIENE 

Several skin diseases caused by parasites may be conveyed by 
barbers to their customers by means of their instruments, hands, 
towels, etc. Among these are barbers' itch, ringworm, boils and 
even carbuncles. The only way to avoid such infections with cer- 
tainty, is for the patron to furnish his own brush and comb, shaving- 
soap, cup and brush, and see to it that the barber cleanses his scissors 
and razor with alcohol and water and uses a clean cloth. Notwith- 
standing the improved methods in barber shops much infection is still 
spread, especially that of dandruff. 

The finger-nails should be trimmed so as to follow closely in outline 
the contour of the finger; the toe-nails should be cut straight across to 
avoid pressure on them by the toe of the boot w T hich may result in 
in-growing toe-nail. 

Clothing. — Tight clothing, and the constriction from rigid or tight 
corsets, belts (the latter in men as well as in women), tight neckwear, 
garters, etc., interfere with the normal functions of the organs they 
cover. All such constriction should be carefully avoided. Only the 
minimum amount of clothing that w T ill secure w T armth should be worn. 

In regard to underclothing, there are two factors of importance: 
First, the property of retaining heat. Of the three fabrics most fre- 
quently used for clothing, wool, cotton and linen, wool is the greatest 
non-conductor and therefore retains heat most effectually. But for 
this reason woolen garments require the least exercise of the tempera- 
ture-regulating apparatus of the body. The second factor is the power 
of absorbing moisture. While wool is also highly absorbent of moist- 
ure, it does not give off moisture quickly enough. Hence, if worn next 
to the skin, it becomes saturated with perspiration, w T hich it long 
retains to the disadvantage of the skin. Consequently woolen cloth- 
ing is best confined to outer garments, designed especially for cold 
weather. Cotton, on the other hand, does not absorb moisture so 
readily, is a better conducting material and drys more rapidly. Linen 
is about on a par with cotton as regards power of absorption of moist- 
ure and retention of body heat. The underclothes throughout the 
year are best made of cotton or linen. In winter merino, that is, a 
mixture of cotton and wool or "double deck" linen and wool, may be 
worn by those who object to wool alone. The linen mesh makes an 
excellent fabric for warm weather, for it imparts a sense of coolness to 
the skin, but it is more expensive than cotton. 

As to color, the more nearly white the clothes the better. This 
is especially true in summer, though there is believed to be some 
advantage in white at all times. Undergarments dyed in bright 
hues are undesirable, as the anilin colors used often irritate the skin 
and produce eruptions. The same effect is sometimes caused by 
colored stockings. The stockings should be changed frequently, 
especially if one perspires freely. The feet should then b. soaked 
in hot w T ater and dusted over with pure boric acid every day. Damp- 
ness of the underclothing from perspiration favors the growth and 
development of disease germs and skin parasites, so that clothes should 



SANITATION OF THE BODY 507 

cither be changed when wet or well aired and dried when they are 
removed. 

Regarding the color of outer clothes, black or dark shades absorb 
the heat rays of the sun much more than white fabrics or those 
approaching white in hue. For this reason white clothes are worn 
in the tropics and in hot weather. 

The amount of clothing does necessarily depend on the temperature, 
although heavy underclothing may be needed for those living out of 
doors in cold weather. Those spending much of their time indoors 
who have become accustomed to clothe themselves properly find that 
they have grown far more independent of changing weather conditions. 
They do not suffer greatly from extremes of heat or cold. In our arti- 
ficially-heated houses, where there is practically a summer temperature 
during winter, it is unwise to wear heavy clothing ; many people acquire 
colds by doing so. It is better to dress as in summer while in the 
house, but very warmly with ulsters, furs, etc., before going into the 
cold. 

Impervious materials, as rubber, leather and mackintosh are, of 
course, unfit for clothing except as a protection against wind and wet. 

Foot- and Head-gear. — Hats should not fit, but shoes should. The 
tight hats generally w r orn by men check the circulation of blood in 
the scalp; but shoes to fit should be made to order from an outline 
drawn of the stockinged feet. Shoes should be nearly an inch longer 
than the foot; the toe should be neither pointed nor absolutely square, 
and the sole should be nearly flat on the bottom. Extension of 
the soles outward around the uppers affords better support for the 
foot. Tight shoes w T ith extremely high heels deform the feet and 
interfere with their health. In all except cold weather, low shoes are 
preferable to high shoes. 

Sanitation of the Body. — Constipation. — In these days everybody 
believes in sanitation of the community. Pure food, pure water, 
efficient sewage, clean streets are desired by all intelligent persons. 
The menace to the individual, however, from unsanitary conditions 
in the community is far less than the menace from unsanitary condi- 
tions in his own body. A clean skin does not necessarily mean a clean 
body. The lining of the food canal and of the intestines is nothing 
more than a continuation of the skin. 

Under the artificial conditions of living, wmich civilization demands, 
this internal skin, as it w T ere, is not always as physiologically clean 
as it should be. The sew^age wastes of the body are not always effi- 
ciently released. This condition of stagnation or sluggish move- 
ment in the self-cleaning functions of the body, which is called con- 
stipation, is so common that it is often accepted as an inseparable 
feature of so-called civilized existence. But it can be prevented to a 
great extent by proper attention to personal hygiene. Constipation is 
not only an important factor in reducing the general level of health, 
but it is, in itself, often an index of low T ered bodily condition. 

The causes of constipation are manifold, but may here be grouped 



508 ADDITIONAL PRACTICAL POINTS IN PERSONAL HYGIENE 

under the general cause of improper habits of living. Heredity plays 
some part, hut the average individual, with good heredity, develops 
constipation because of the artificial conditions of his life. Lack of 
exercise, faulty diet, and neglect of the bowel function, are the promi- 
nent causes. Another important cause of constipation is the constant 
use of laxatives and purgatives. Many purgatives, even those com- 
monly considered harmless, such as laxative salts and mineral waters, 
are often distinctly harmful, causing a chronic inflammatory condition 
of the bowel or aggravating the already existing inflammation that is 
present. The chief error in diet that induces constipation is the use 
of concentrated food. Such food leaves little residue or waste to 
stimulate the bowel movement. The intestinal contents become 
dangerous by being long retained, as putrefying fecal matter contains 
poisons which are harmful to the body. Abnormal condition of the 
intestines are largely responsible for the common headache and for 
general lowered resistance, resulting in colds and even more serious 
ailments. Constipation is extremely prevalent, partly because the 
diet of most people usually lacks bulk or other needed constituents, 
but partly because they fail to eliminate regularly, thoroughly and 
frequently. 

Free water drinking when the stomach is empty, especially before 
breakfast, is beneficial in constipation. Free water drinking at meals, 
on the other hand, may prove constipating. Excess of w r ater should 
be avoided by the very feeble or those suffering from heart disease or 
dropsy. Six or eight glasses of water a day is the normal amount. 

The best regulators of the bowels are foods. Foods should possess 
sufficient bulk to promote the action of the intestines and should 
contain a due amount of laxative elements. Foods which are espe- 
cially laxative are prunes, figs, most fruits except bananas, fruit juices, 
all fresh vegetables, especially green of all sorts, wheat bran, and the 
whole-grain cereals. Foods with the opposite tendency are rice, boiled 
milk, fine wheat flour in bread, cornstarch, white of egg. 

The use of wheat bran in cereals, in bread and even in vegetables is 
a prevention of constipation, as is also the use of agar-agar. This 
is not digested and absorbed, but acts as a water carrier and a sw 7 eep 
to the intestinal tract. It should be taken without admixture with 
laxative drugs. Paraffin oil is especially good as an intestinal lubri- 
cant to assist the food to slip through the intestinal canal at the proper 
rate of progress, provided the oil is first freed, by long shaking with 
water, from certain impurities. Taken several times a day, oil may 
retard secretion of gastric juice and also interfere w T ith absorption of 
food. 

In general cathartics should be avoided, since certain drugs are 
often harmful, when their use is long continued, and the longer 
they are used the more dependent on them the user becomes. The 
occasional, but not habitual, use of an enema with warm water (fol- 
lowed always by a second enema of cool w T ater to prevent relaxation) 
is a temporary expedient. 



-* 



SANITATION OF THE BODY 509 

Massage of the abdomen, deep and thorough, with a sweeping 
movement of the fingers on the left side of the abdomen from above 
downward, also promotes the process of defecation. 

The normal man and woman should find no difficulty in having 
complete movements regularly two or three times a day by merely 
living a reasonable life, being careful especially to avoid overfatigue, 
to take regular exercise, including in particular, deep breathing exer- 
cises, and to maintain an erect carriage. 

The natural instinct to defecate, like many other natural instincts, 
is usually deadened by failure to exercise it. Civilized life makes 
it inconvenient to follow this instinct promptly. The impulse, if 
neglected even five minutes may disappear. There are few health 
measures more simple and effective than restoring the normal sensi- 
tiveness of this important instinct. It may require a few weeks of 
special care, during which cold water enemas at night, following 
evacuation by paraffin oil injection, may be needed, until the normal 
two or more evacuations a day are reestablished. 

Posture. — One of the simplest and most effective methods of per- 
sonal hygiene to avoid self-poisoning is by maintaining an erect 
posture. In an erect posture the abdominal muscles tend to remain 
taut and to afford proper support to the abdomen, including the great 
splanchnic circulation of large bloodvessels. In a habitual slouching 
position the blood of the abdomen tends to stagnate in the liver 
and the splanchnic circulation, causing a feeling of despondency 
and mental confusion, headache, coldness of the hands and feet, and 
chronic fatigue or neurasthenia and often constipation. A slouching 
attitude is frequently the result of disease or lack of vitality; but it is 
also a cause. 

Many persons who have suffered for years from the above-named 
symptoms have been relieved of them after a few weeks of correct 
posture, sometimes reinforced by the artificial pressure of an abdominal 
support and by special exercises to strengthen the abdominal muscles. 

In walking, the most common error is to slump, with the shoulders 
rounded, the stomach thrust out, the head thrown forward, chin up, 
and the arms hanging in front of the body. It is characteristic of 
these with weak muscular and nervous systems. To set the shoulders 
back and square them evenly, to keep the chest high and well arched 
forward, the stomach in and the neck perpendicular like a column, 
and the chin in, are simple fundamental measures that most persons 
know and many disregard. 

But it is not enough to have an erect carriage and a well-poised 
head; one should also have well-directed feet. Weak feet, and its 
final stage flat feet, are more common among women than they are 
among men, because it is not a purely local condition in the arch of 
the foot, as many suppose, but primarily due to a general weakened 
condition of the leg muscles that support the arch. The more vigor- 
ous exercise of boys as compared with that of girls probably protects 
them in some degree from this trouble, 



510 ADDITIONAL PRACTICAL POINTS IN PERSONAL HYGIENE 

Weak feet are gradually converted into flat feet by faulty standing 
and walking posture and lack of leg exercise. Toeing out, whether 
walking or standing, so commonly noted among girls and women, places 
a great strain upon the arches of the foot. The correction of this fault 
by persistent toeing in, Indian fashion, and daily exercise of the leg 
muscles (rising on the toes twenty to thirty times night and morning) 
will do much to prevent flat feet. 

Not only in standing, but in sitting, erect posture has been found 
to be a much more important factor in the maintenance of good health 
than is generally supposed. In sitting at a desk or table, when 
reading or working, the common fault is to adopt a sprawling attitude, 
with the shoulders hunched up, the elbows stretched forward, the 
body too far away from the desk or table and the weight resting on 
the buttocks. Very often the desk or table is too high, and the 
arms cannot rest easily upon it, thus causing a certain strain on the 
structures around the shoulder-joints. 

To correct this fault, let the person use if possible a chair with a 
back curved forward and sit well back in the chair, but close to the 
desk, so that the fleshy inner part of the forearms may rest easily 
upon its surface without pushing up the shoulders. The arms should 
hang easily from the shoulders and the elbows should not rest upon 
the table. The shoulders should be evenly square, as in the correct 
standing posture. In right-handed persons the light should fall over 
the left shoulder or directly from above. The body should rsst upon 
the full length of the thighs, not solely on the buttocks, and the feet 
(not legs) be crossed and resting lightly on the ground on their outer 
edges. In other words, the position should be freed from strain, espe- 
cially strain of special groups of muscles. 

Pains, falsely ascribed to rheumatism, writer's cramp and many 
other needless troubles are often caused by faulty posture in working 
or reading. 

In children faulty posture may mar the future of the individual 
by causing spinal curvature and physical deformities that interfere 
with physical and mental efficiency throughout life, and often lowers 
the resistance to disease. Deep breathing through the nose and 
"setting up" exercises are of great value in such cases. 

The teaching of proper standing, proper walking and proper sitting 
should be a part of all school discipline as it is at military schools, 
especially as there is the temptation to crouch over the school desk — 
which is usually the source of the first deviation from natural posture. 

Care of Mouth, Teeth and Gums. — There are two forms of mouth 
danger — dental caries or decay, which is at first largely a chemical 
process and affects the tooth proper, and pyorrhea or Rigg's disease, 
which affects the tissues surrounding the root of the tooth, and is 
accompanied with infection by pus bacteria and possibly also by animal 
parasites, termed entameba. Scrupulous cleanliness of the mouth 
largely prevents both of these maladies. 

In caries, or dental decay, plaques or films of mucin from the saliva 






SANITATION OF THE BODY 511 

form on the tooth surfaces and enclose bacteria and particles of car- 
bohydrate food, which undergo fermentation with the formation of 
lactic acid. This dissolves the lime salts on the surface of the teeth, 
leaving only the organic matter, which is then attacked by bacteria. 
Putrefaction sets in, and a cavity is formed. This cavity is a menace 
to health, as it harbors various forms of bacteria, which infect the 
general system through the root canals, -or the digestive system by 
being swallowed with the food. It may also give rise to abscesses 
at the root tips. 

Pyorrhea is an infection of the gums or tooth sockets. It begins 
beneath the edges of the gums that have been injured and especially 
when there has been an accumulation of tartar or lime deposits. As 
the infection progresses and destroys the membranes that attach the 
root of the tooth to the socket, a pocket is formed around the root and 
the tooth becomes loosened. This disease is said to be responsible for 
far more loss of teeth than decay. 

But the evil does not step here. In the pocket pus is continually 
being formed and discharged into the mouth and swallowed. Also 
the teeth rise and fall in their diseased sockets in chewing, bacteria 
are forced into circulation and may be carried to distant parts, where 
they work harm. 

It was formerly supposed that the ill effects from such conditions 
as dental decay, abscess and other pus foci were wholly due to toxins 
or poisons thrown off in the blood stream by bacteria at the focus. It 
is now known, however, that the bacteria migrate into outside tissues 
through the blood and lymph streams. In joint affection, they clog 
and obstruct the small bloodvessels, interfering with the nutrition of 
the joint tissue, causing deformity and enlargement, as in arthritis 
deformans, as well as in acute inflammation, such as rheumatic fever. 
Indeed, this condition of subinfection or focal infection is becoming 
recognized as a far more important cause of disease than the so-called 
"auto-intoxication." At any rate it is a sufficient cause of disease to 
justify a vigorous campaign for the better care of the teeth and for a 
thorough search for mouth-infection in every case of obscure disease. 

Gum infection is not always due to conscious neglect. Some 
people do not know how to properly cleanse the teeth. Others 
have tissues of low resistance and need to give extra care to tooth and 
gum cleansing under the closest dental supervision. Others, again, 
have spent large sums for dental work that filled the mouth with 
crowns and bridges difficult to keep aseptic or surgically clean. There 
are various means which can be used to prevent or cure these dental 
evils. 

First, the importance of general hygiene, in order that a general 
resistance to mouth infection may be built up, cannot be overesti- 
mated. . The cultivation of normal eating habits with respect to 
the vigorous use of the jaws by thorough mastication, the eating of 
hard, resistant, crusty foods every day is the next desirable means of 
tooth and gum hygiene. 



512 ADDITIONAL PRACTICAL POINTS IN PERSONAL HYGIENE 

The teeth, gums and tongue should be cleaned night and morning 
and after each meal, if possible, by rapid rotary brushing. Strong 
pressure is hot advisable. Rapidity of movement is the important 
point. This stimulates the circulation and increases the resistance 
of the gums and cleanses the teeth at the margins from the accumu- 
lations of tartar which being at first soft are easily removed by a 
brush. A brush should be used with bristles that are stiff and of 
different lengths, so that the innermost crevices of the teeth may be 
reached. If the gums are sensitive a moderately stiff brush can be 
used until the gums can bear the more vigorous treatment. The 
tongue should also be carefully cleansed with the tooth brush. Tooth 
powders and pastes may be used, but should not be the main reliance. 
Some powders, if used too freely, are liable to unduly thin the enamel 
of the teeth. The use of dental floss silk between the teeth, provided 
care is taken not to press it against the gums, is also helpful. 

A number of investigators have reported the presence of an animal 
parasite — Entameba buccalis — in all cases of pyorrhea, and it is thought 
that this parasite may be one of the causative factors in this disease.. 
Emetin, the active principle of ipecac, which has been successfully used 
in the vegetative stage of amebic dysentery, has been proposed for the 
treatment of this trouble. Such a remedy should only be used, if at all, 
in connection with thorough surgical treatment and dental prophylaxis. 
It is claimed that in the early stages of pyorrhea a mouth wash com- 
posed of 2 drops of fluidextract of ipecac to a half-glass of water is 
Aery serviceable. As at that stage a mouth w T ash is entirely harmless, 
it may be tried, especially as it is now thought that some degree of 
pyorrhea or entamebic infection is almost always present. 

For an alkaline wash, there is nothing better than lime-water, made 
from coarse unslaked lime; alkaline washes, however, are very super- 
ficial in their action, while fruit acids coagulate and thus render remov- 
able the mucin plaques and prevent the formation of tartar. They 
also cleanse the tongue and membranes of the mouth generally, which 
may be important sources of infection. These acids are found in 
grape-juice, orange-juice, lime- or lemon-juice, apple, etc. Such 
mechanical cleansing is particularly important before retiring, as it is 
usually during the night that the most damage is done. But the con- 
dition of the teeth must be determined, especially as to whether there 
is any erosion or destruction of enamel, before either alkaline or acid 
washes are used exclusively. Periodic examinations and cleansings 
by the dentist are the only safe measures. 

Until lately too much attention has been given in this country to the 
saving of the teeth, without fully realizing the dangers of infection from 
the mechanical devices employed. The teeth should not be extracted 
on mere suspicion and without proper effort to save them, but it is far 
more important to save a person from some remote infection than it 
is to save his tooth, not that all crown and bridge work is improper, 
but such work should be of a character only that will admit of surgical 
cleanliness in the mouth. Moreover, teeth so treated should always 



SANITATION OF THE BODY 513 

be examined by .r-ray, when there is evidence of systemic disease, in 
order to be sure that the roots and sockets are not infected. 

In early life the jaws should be carefully examined to determine 
whether or not the proper development is taking place. If the upper 
and lower teeth fail to articulate, extra strain is placed upon certain 
teeth and the sockets are liable to injury and infection. Faulty devel- 
opment can often be corrected and deformities that interfere with 
mastication can then be avoided. 

The temporary teeth should not be allowed to be removed by decay. 
Thorough dental and personal care should prevent this. If cavities 
form, they should be filled under proper precautions and the teeth 
should be saved as long as possible, unless they are causing infection. 

Care of the Eyes. — Defective vision may be a cause or a sign of ill 
health. Therefore when there is trouble with the eyes an oculist 
should be consulted. But there are several things which a person 
may be taught to do to care for his own eyes. The eye, like other 
organs, has its factor of safety; that is, it will stand considerable abuse 
and it is protected from injury in many ways, but if the eyes are very 
much overstrained they suffer seriously. 

The common eye defects such as astigmatism, myopia and hyper- 
metropia can usually be corrected by glasses. The defect having been 
found and glasses fitted, the condition of the eyes should be checked up 
every year or two, as in some people frequent changes of glasses are 
necessary because of changing conditions with advancing years. 
Even after proper glasses have been fitted, eye strain may be brought 
about by the overuse or improper use of the eyes. Persons whose eyes 
are easily fatigued should be told not to use them continuously, but to 
give them occasional rest. Eyes that are free from disease and opti- 
cally perfect may be overstrained by too much use, and simple rest will 
relieve this condition also as well as such accompanying symptoms as 
headache and nervousness. Many people suffer seriously from eye- 
strain as the result of too frequent attendance at moving-picture 
shows. Headache, nervousness and inflammation of the eye-lids on 
the day following are not unusual and should be a warning to take 
more care of the eyes. 

Among the number of faulty reading or working habits that produce 
eye-strain are the following: 

Insufficient Illumination. — Reading or working in a dim or flickering 
light especially at the close of day when twilight is coming on. 

Excessive Illumination. — Reading or working in the direct glare of 
the sun or by close, direct electric or lamp light. 

Faulty Posture in Reading or Working. — Facing the light or having 
the back to the light, or the light directed over the right shoulder when 
writing or working. Reading in a cramped position or when lying 
down. Reading on trains or when walking. 

A very common error is the use of a brilliant desk light. The best 
light is an indirect diffused light of sufficient strength to make the 
letters on the page stand out black and clear and of uniform distinctness. 
33 



514 ADDITIONAL PRACTICAL POINTS IN PERSONAL HYGIENE 

Exposure to excessively brilliant light will sometimes bring on 
inflammation of the eyes, or even temporary blindness, as in snow- 
blindness. At the seashore and on the water, or in the winter time 
when traveling over the snow, amber glasses will add to the comfort 
and prevent eye-strain. If a person works facing a window, it is 
advisable to wear an eye-shade, otherwise there is a struggle between 
the tendency of the bright light to close the pupil and the tendency of 
the work required to keep it open. 

The reflex evils from eye-strain are great and numerous and are 
often incorrectly ascribed to entirely different causes. Headache, 
nausea and dizziness are especially frequent results of eye-strain. 
Some of the breakdowns in middle life may be due primarily to the 
reflex effect of eye-strain. 

Eye-strain is to be prevented by scientifically adopted spectacles, 
by care to secure the right kind of illumination, and in some cases by 
systematically resting the eyes. 

Exercises with Rest. — By exercise in general is meant muscular exer- 
cise. To offset the evils of a sedentary life, it is advisable to spend one 
hour daily, or at least fifteen minutes, in some kind of vigorous muscular 
exercise. 

The sewing-machine is probably the most beneficial form of medicinal 
home exercise that is likely to be followed faithfully. Simple stretching 
in bed when a person wakes up is helpful, especially if combined with 
breathing exercises. 

The most beneficial exercise, as a rule, is that which stimulates the 
heart and lungs, such as running, rapid walking, hill climbing and 
swimming. These should, of course, be graduated in intensity with 
varying age and different degrees of activity. 

Gentle muscular exercise after meals promotes normal digestion 
and should be practised for a quarter of an hour after each meal, but 
violent exercises immediately after meals should be avoided as a large 
amount of blood is thus engaged by the digestive system. 

A Aery important fact to be impressed upon the average man is 
to take into consideration that, whereas he naturally gets some outdoor 
exercise in summer, he is apt to allow it to lapse in the winter. Such 
a decided change in the amount of exercise is dangerous and should 
be guarded against by taking regular gymnasium exercise. 

Systematic exercise is important and beneficial, even when the 
individual finds it uninteresting. But, although exercise when self- 
imposed is wholesome, exercise to which one is naturally attracted is 
more so. Golf, horseback riding, tennis usually inspires enthusiasm, 
and enthusiasm itself is healthful. Walking may also do so if the 
walk has an object, as in mountain climbing, rowing, polo-playing 
and other sports. 

There is considerable evidence that college athletics often seriously 
injure those who engage in them, although they were originally encour- 
aged for the precisely opposite effect. The value of exercise consists 
not in developing large muscles nor in accomplishing athletic feats, 



SANITATION OF THE BODY 515 

but in obtaining physical poise, symmetry of form, and the harmonious 
adjustment of the various parts of the body, as well as in furthering 
the proper activity of cell tissues and organs and the elimination of 
waste products. 

Even those whose work is largely muscular, unless it involves most 
of the muscular system, may do well to exercise the unused muscles. 
It is distinctly unhealthful either to overdo or underdo work, rest or 
exercise. Not all persons are in need of exercise, nor are all in need 
of rest; but almost everyone needs to change the proportion between 
the two. Today many people are suffering from too much or too little 
work. 

Useful, purposeful work not only inspires interest and enthusiasm, 
but it is necessary for a normal healthy life. Work when done with 
zest is an invigorating tonic. Exertion of any kind is usually agreeable 
at first, and becomes drudgery only when too much protracted. 

Methods of preventing or correcting overstrain vary greatly, 
according to the kinds of overstrain. In general, overstrain of any 
kind tends to fatigue and is therefore to be avoided. A very moderate 
degree of fatigue is perhaps normal, but anything approaching 
exhaustion should be forbidden. 

Working hours should be so arranged as to enable the worker to 
fully recover over night, partly from sleep and partly from the recrea- 
tion enjoyed in leisure between work and sleep. 

Variety of work is especially needed at the present time, when 
specialization tends to lead men to extremes. Changes in work 
which present a sense of monotony will greatly increase the power 
to work. 

Not only the functions of the body but those of the mind require 
exercise — exercise in thinking, feeling and willing. The exercise of 
the will is of first importance. The will is exercised every time a 
decision is made. One of the advantages of all games is that they 
require decision by the players. 

Since the work of most people is likely to produce some unhygienic 
element which cannot be avoided, a compensation should be sought 
in an avocation or "hobby" to be practised out of regular working 
hours; and the avocation should be far removed from the nature of 
the regular work. But play itself should not be turned into work. 
Recreations should be enjoyed for their own sake, or else they are not 
recreating. 

Play is a half-way stage between work and rest. In a hygienic 
life there must be a certain amount of actual rest. Every bodily power 
requires rest after exertion. The muscles require relaxation after 
every contraction. The man who is always tense in muscle and 
nerve is wearing himself out. 

The power to relax when fatigue requires it is one of the most impor- 
tant safeguards to health. Lying down when tired is a good rule for 
hard working people. Idle and lazy people rest too much. Relaxa- 
tion is only a short vacation, as it were, between two activities. 



516 ADDITIONAL PRACTICAL POINTS IN PERSONAL HYGIENE 

Bathing and swimming supply in their numerous forms examples of 
both healthful activity and relaxation. A cold sponge or shower, 
alternated with hot, affords excellent gymnastics for the skin. A 
very hot bath lasting only a minute, or even a hot footbath is restful 
in cases of fatigue; but the neutral or tepid bath is the most restful 
of all. 

The nervous relaxation induced by neutral baths is an excellent 
substitute for sleep in cases of insomnia, and often it induces sleep as 
well. Neutral baths are now used not only in cases of insomnia, but 
also in cases of acute mania. 

Sleep may also be induced by monotonous sound or lack of sound, 
or the monotonous holding of the attention. Keeping awake is due to 
continued change or interruption or arrest of the attention. 

Exercise taken in the afternoon will often promote sleep at night 
to those who find sleep difficult. Slow, deep, rhythmic breathing is 
useful when a person is wakeful, partly as a substitute for sleep and 
partly as an inducer of sleep. 

Sleep being Nature's great restorer should be enjoyed to the full. 
Sleep should not only be sufficient in duration but also intensity and 
regularity. The number of hours of sleep generally needed varies 
with circumstances; the average is seven to nine. Generally a person 
should sleep when sleepy and not try to sleep any more. Growing 
children require more sleep than adults, and women, as a rule, more 
than men. 

The best sleep is with the stomach empty. Food may put one to 
sleep at first by directing blood from the head; but it disturbs sleep 
later. As already pointed out, sleeping out-of-doors is more restful 
than sleeping indoors. 

The character of sleep depends largely on the mental attitude of 
the person on going to bed. The habit should be cultivated of dropping 
work and cares at bedtime and thinking only of pleasant things. If 
worries are taken to bed the sleep cannot be restful. 

Serenity and Poise. — If a person is to be really healthy his mental 
attitude must be healthy. A healthy mental attitude implies many 
elements, but they may be all summed up in the word "serenity." 
Probably no other one hygienic requirement is of greater importance 
than this. Moreover, the attitude of " healthy-mindedness " should 
be encouraged not only in order to produce health, but as an end in 
itself, for which, in fact, even health itself is sought. In short, the 
health of the body and the health of the mind act and react on each 
other. 

Serenity may generally be kept through following the other meas- 
ures already described. Discontent is undoubtedly very often the 
consequence of wrong conditions in the body, and through melancholy, 
worry, peevishness, fear, is apt to appear as arising from outward con- 
ditions, but there are usually real physical sources, existing within the 
body itself. A person who is physically ill is likely to be ill-satisfied 
with everything and without suspecting the fundamental cause of 



SANITATION OF THE BODY 517 

the discontent. When the oppressive "cause" is removed, the dis- 
content remains none the less, and is attributed to something else. 

Among physical conditions which are often accompanied by mental 
depression and fatigue are the near approach to the menstrual period 
in women, constipation, eye-strain, or the effects of alcohol or other 
drugs, a sedentary life, a bad posture or weak abdominal muscles — 
all of which may be corrected by the proper observance of personal 
hygiene. 

There is, however, a danger to which some people are especially 
subject — the danger of paying too much attention to physical hygiene. 
Such a person becomes fearful lest he is not doing exactly the right 
thing. He looks suspiciously at every article of food and fears that it 
will disagree. He fears that he has strained his heart; he worries 
over the loss of an hour's sleep; he chafes because he has not got his 
vacation at the right time or of the right length. The hypochondriac 
thus neutralizes practically all the benefit of the hygienic measures by 
disregarding this special measure of keeping serene. 

On this theory the devotees of mind-cure cults have derided every 
hygienic measure but their own. But it is a great mistake to stake 
everything on the simple resource of mental equanimity. In some 
cases it is criminal, as for instance to neglect surgery for cancer, or 
antitoxin for diphtheria, or outdoor living for tuberculosis, though in 
its proper place " mind-cure" is an essential part of personal hygiene. 
In order to get the benefit of other rules, there must be no worrying 
or watching of symptoms. 

Incessant worry, even if mild, is more exhausting than occasional 
fits of anger or fright or overexcitement. If unceasing, worry will 
often drain away the largest store of nervous energy. Worry, as it 
were, short-circuits nerve currents in the brain, which normally form 
long circuits through the body. 

Each must, of course, learn for himself how to avoid anger, fear, 
worry, excitement, hate, envy, jealousy, grief and all depressing or 
abnormal mental states. To do so is an art to be practised. But 
much can be done by instruction. 

Most people are inclined to live too many days in one, which tends 
to disturb their serenity. Wlien this condition becomes inseparable, 
it can often be changed by "living one day at a time." Almost every- 
one has it in his or her power, for merely one day or at any rate one 
hour, or one minute, to eliminate fear, worry, anger or other unwhole- 
some and disturbing conditions; and this should be cultivated and 
encouraged. 

Modern life in this country has been gradually speeded up to the 
breaking point and many people are suffering from a constant oppres- 
sive sense of hurry — they have "so much to do" that they cannot do 
it, and this fact urges them on in the vain endeavor to catch up. They 
must be brought to realize that the sense of hurry actually reduces the 
effective speed of work — in other words, that "the more haste, the less 
speed." 



518 ADDITIONAL PRACTICAL POINTS IN PERSONAL HYGIENE 

Professor William James commends as an aid to mental hygiene the 
adoption of a "religion of healthy-mi ndedness," in which all wrong or 
diseased mental states are removed, and only the healthy ones, such as 
courage, patience, optimism and reverence are cultivated. 

When the mind turns from shadow to sunlight, the body will tend 
also to assume the radiance of health. There is no duty so much 
underrated as the duty of being happy. The habit of being happy 
enables one to be freed, or largely freed, from the domination of 
outward conditions. Though this trait is apparently totally lacking 
in some, while existing in others to a high degree, experience has shown 
that it can be cultivated. 

The secret of equanimity consists not so much in repressing fear or 
worry as in dropping or ignoring it, that is, directing and controlling 
the attention. This is the main art of mental hygiene, and it is a very 
important, though much neglected, branch of personal hygiene. 



CHAPTER XXI. 

MILITARY HYGIENE. 

By C. W. BERRY, M.D. 

Military hygiene is a term used when the principles of hygiene are 
applied to bodies of troops and their environment. 

These principles are not new to the student of preventive medicine, 
but situations are presented which make their application difficult, 
and in many cases the only choice in a difficult problem is the lesser of 
two evils. 

At first thought it would appear that in a military body where the 
men are all selected specimens, and an order of any kind is immediately 
obeyed, that all difficulties as to the enforcement of recognized sanitary 
laws had been removed, and a camp or post where soldiers are quartered 
should be an example to the outside world of the soundness of hygienic 
teachings. The stumbling block to this lies in the fact that military 
bodies are created primarily for war, and hygienic principles have to 
take second place to military necessity. A commander of troops can 
seldom consider the health conditions of a location to which his troops 
may move, the military advantages of the terrain being the more 
important for the time being, and more often he has no choice as to the 
site on which he must meet the enemy. 

Another factor to be considered is that large bodies of men are obliged 
to live for long periods of time in close contact with each other, thus 
greatly increasing the probability of disseminating any chance infec- 
tion. Experience has taught us that communicable diseases are very 
apt to appear or spread rapidly in a military camp in spite of the 
precautions that are taken to avoid them. 

In the study of military hygiene it is well to commence where an 
army begins, namely with the recruit, and then follow him throughout 
the different phases of the service he may encounter. In this way a 
good working knowledge of the problems and difficulties that confront 
the hygienist in military life may be acquired, and also some of the 
means used at the present time to preserve the health of our armies, 
and to keep them in such condition as to render the greatest service. 
The problem of the doctor in the army is not only to keep his command 
well, but to return to duty as quickly as possible all men incapacitated 
either by illness or wounds, so that his list of non-effectives may be 
kept as small as possible. 

THE RECRUIT. 

Men who desire to enter the military service must meet certain 
requirements as to height, weight and physical condition, and broadly 



520 MILITARY HYGIENE 

speaking, less than 50 per cent, of those applying are accepted for 
enlistment in times of peace. 

The following standards were in effect before the War with Germany.; 
Age. —Eighteen to forty-five years. 

Height. — From a minimum of 64 inches to practically no limit, 
provided the candidate is properly proportioned as to weight, chest 
measurements, etc. For some branches of the service as the Cavalry 
or Field Artillery, the maximum is 70 inches. 

Weight. — The rule is two pounds of weight for every inch in height 
and five additional pounds for every inch above 07 inches. 

Chest Measurement. — Between 04 and 67 inches in height the mean of 
the chest circumference should be 33 inches, or about half of the 
height, with a mobility of two inches. The minimum at expiration is 
32 inches. 

It is permissible to enlist by special authority men with special 
qualifications who may deviate slightly from the above figures. 

The physical examination as outlined in General Order 66 (War 
Department) is a rigid one, and embraces tests of the vision and hear- 
ing, and a thorough examination of the entire body, and the normal 
working of its different functions. 

In time of war when troops are urgently needed, the standards are 
often lowered, and men accepted who under peace conditions would be 
rejected. War Department Bulletin 133, of July 14, 1917, reduced 
the minimum height to 61 inches and weight to 110 pounds. 

The reduction of accepted standards for recruits is sometimes fol- 
lowed by disastrous results, the recruits thus obtained being unable to 
stand the rigid training and severe hardships of a campaign, and 
actually impede progress by crowding the sick report of their organiza- 
tion, and later the pension roll of the nation. 

The life of a soldier during times of intensive training in preparation 
for battle is not an easy one. His time when in mobilization camp is 
fully occupied with more or less strenuous work, to which may be added 
long marches or hikes, each man carrying forty to sixty pounds, digging 
trenches and ditches, cutting up trees for fire wood, exposure to all 
kinds of weather, irregular meals, poor cooking and often a night in 
the open with no shelter or protection from the elements. 

An ordinary day's work in camp is shown by the following schedule: 
First call, 6 a.m. 
"Assembly, 6.15 a.m. 
Mess, 6.35 a.m. 
Sick call, 6.55 a.m. 
Fatigue, 7a.m. 
Drill, 7.30 to 11.30 a.m. 
Mess, 12. 

Drill, 1 p.m. to 5 p.m. 
Retreat, 5.40 p.m. 
Mess, (> p.m. 
Taps, 11 p.m. 






THE RECRUIT 521 

The eight hours given to drill are fully occupied, the men being on 
their feet and undergoing active physical exertion, other camp duties 

being outside of these hours. 

During actual service at the front in time of war, all hardships are 
greatly increased, and it is often necessary to push troops to the limit 
of human endurance that positions may be held or taken. 

The class of recruits obtained is a factor in military hygiene. Men 
from country districts are usually better specimens of physical man- 
hood but, on the other hand, on account of their isolated manner of 
living have not developed immunity from the common communicable 
diseases. It is among these men that epidemics of mumps, measles, 
scarlatina, epidemic meningitis, etc., break out, and spread with special 
virulence. 

Men from cities are usually of the mechanic class and make good 
soldiers, although their habits are at times objectionable. Men 
between the years of eighteen and twenty-five are most amenable to 
discipline and military training, those of more mature years are usually 
set in their habits and hard to break into the rigid regime of a well 
trained army unless they have had previous military training. 

Men over forty-five years of age as a class are not able to endure the 
hardships of a rigorous campaign, and as a rule do not accompany first 
line troops. 

It is essential that recruits be of good character, and of average 
mentality, those whose habits will not bear scrutiny are a menace in the 
army, their example being readily followed by the more susceptible and 
younger men. 

Regarding those of low grade mentality who now and then slip by 
the examining physician, the best that can be said is that the sooner 
they are eliminated the better; they are the despair of the drill instruc- 
tor, are continually in the guard house for breaches of discipline and 
are a nuisance to the entire organization, the actual cause of deficiencies 
rarely being recognized outside of the medical department. 

In this connection, it might be well to point out a class of men of 
unstable nervous organization, who, after a few months of army life, 
break down mentally or become neurasthenics. Sometimes an attempt 
is made to simulate insanity so that punishment of delinquencies may 
be averted, or release from military service obtained. Much may be 
done by company commanders to prevent nervous disorders by a 
judicious use of games, athletic sports, etc., and seeing personally that 
all of their commands take part and are interested in the different diver- 
sions. Men must not be allowed to mope around their tents avoiding 
their fellow soldiers ; good healthy companionships are to be encouraged, 
and the contrary broken up. 

Having thus obtained a fair specimen of manhood as a recruit for 
the service, the next step will be to furnish him with the regulation 
clothing and equipment, and train him in the duties of a soldier. 



522 MILITARY HYGIENE 

CLOTHING. 

The clothing of a soldier must fill certain requirements, both military 
and hygienic. 

Military fashion insists on a certain smartness and ornamentation, 
a distinctive color and fit that makes the wearer take pride in his 
profession. Since modern warfare made the wearing of bright colors 
and ornaments dangerous on the battle-field, two uniforms are now 
issued, namely, the olive drab service uniform of a brown hue, which 
matches well with the landscape and makes the wearer invisible at 
medium distances, and the full dress uniform of blue, with various 
trimmings according to the arms of the service. 

Hygiene on the other hand demands that the head gear shall protect 
from the tropical sun in the summer, and also protect the head, ears and 
neck during service in cold climates. The other clothing of cotton or 
wool must be such that the wearer can do hard work without being 
hampered by his clothing which must be loose fitting and yet preserve 
that military smartness which is part of the profession of the soldier. 
The shoes especially need care in selection, and are treated of more 
fully in the section on troop movements. 

All of these requirements cannot be met by any one uniform, and the 
problem has been disposed of by the issue of different articles according 
to the service to be performed, for instance, the man going on duty in 
our Philippine possessions would need a different outfit from the 
soldier going to a post in northern Alaska. 

From a hygienic standpoint, the full dress equipment is not desirable, 
the tight fitting blouse with upright tight collar, which compresses the 
neck, is uncomfortable to say the least, and comfort has in many cases 
been sacrificed for military smartness, still as these uniforms are worn 
for short periods of time only, their effects on the health of the organ- 
ization can be ignored. 

The service uniform either of cotton or wool with flannel shirt, service 
hat (Montana peak) , canvas leggings, and well-fitting shoes on the other 
hand admirably fit the need of the American soldier and give him the 
maximum protection from heat and cold, without impeding his move- 
ments. 

For protection against rain, the poncho or slicker is issued which, when 
correctly worn, offers much protection from inclement weather, and in 
addition is used to put under the bedsack to keep off the dampness of 
the soil when sleeping on the ground. The so-called overseas cap, 
issued to the American troops in Europe during the War with Germany, 
was a good example of what a head covering ought not to be, as it 
afforded no protection for the face and eyes from the storms, or the 
rays of the sun. 

The recruit when enlisted draws the following articles from his supply 
officer : 

1 bedsack (an empty tick which is filled with straw and used for 
a bed). 



CLOTHING 523 

2 olive drab wool blankets. 

2 pairs of breeches (cotton and wool). 

1 waist belt. 

1 service hat and cord. 

1 pair of canvas leggings. 

2 pairs of shoes. 

4 pairs of stockings. 

3 pairs of drawers. 
3 undershirts. 

1 identification tag. 
1 overcoat. 
1 shelter half. 

1 poncho. 

2 flannel shirts. 
Toilet articles. 

The hygienist is principally interested in two problems in connection 
with the clothing of a soldier, the first being to see that he actually 
gets the clothing allowed, the second to see that it is worn properly 
and kept clean. 

Often an organization will be unable to draw needed articles of 
clothing for a long time on account of shortage, or other causes of delay, 
and this may be an actual cause of suffering among the men, as for 
instance, only being provided with summer clothes and being suddenly 
shifted to a cold climate without proper equipment. AYhen such an 
event occurs, shift must be made by local purchase and apportioning 
the heavy clothing possessed among the men until suitable equipment 
can be provided. Precautions must also be taken against increased 
chances of infection by common colds and respiratory infection due to 
exposure. 

The men's quarters can be "made as comfortable as possible, plenty 
of straw provided for warm beds, and outdoor work reduced to a 
minimum and performed during the warm parts of the day. Any 
overcoats in the command can be distributed among those on guard or 
whose duties require them to be exposed for long periods of time. Active 
exercise is a good way to keep warm if the men do not have to stand 
around afterward without protection. In camp, where little or no 
shelter is available, large camp fires around which the men can gather 
are a help. 

Regular inspections of the soldier's person and equipment are pro- 
vided for in Army Regulations, and are a means of keeping a check on 
the cleanliness of the individual soldier. Inspection should go further 
than merely looking over the clothing and material spread out for 
observation. Soldiers have been known to wear the same underwear 
for weeks, keeping one or two sets scrupulously clean, ready for inspec- 
tion at any time, but never wearing them. Others will go without the 
undershirt or drawers or even socks as causing too much bother. 
Many do not take time to undress at night, but turn in and get up 
ready dressed, sometimes even to shoes, unless properly watched. 



524 MILITARY HYGIENE 

These habits arc the kind which promote the breeding- of pediculi, 

and sometimes cause the infection of all in the command, especially 
when the bathing facilities are limited. During cold weather, unless 
special care is taken, such customs become general. 

During actual service at the front, as when a regiment is occupying a 
place in the fighting line, little or no attention can be given to personal 
hygiene, and it is not unusual for men to go two or three weeks without 
a chance to change their clothing or clean up in any way. It was found 
in the War with Germany, that a unit that had served any length of 
time in the front lines, was always badly infected with body lice on 
its return to a rest camp, and one of the duties of the medical staff 
was to take care of the so-called de-lousing process at that time. 

By instilling proper habits in these matters, the medical officers 
can do much along the lines of preventive medicine. 

"The excellence of an organization is judged by its field efficiencv." 
I. D. R. 

EXERCISES. 

The underlying principle in the training of a soldier is to increase the 
probability of success in battle. This implies that a high grade of 
physical efficiency and endurance is to be reached and maintained by 
each individual. To effect this, systematic exercises are planned and 
executed in the form of drills, setting up and athletic exercises, marches, 
use of weapons, etc. These are commenced gradually and increased 
to a maximum as rapidly as the recruit is able to stand the work. 

The following schedule is given as an example of the work outlined 
for the men in one of our training camps during the War with Germany. 

The time devoted to training each week was forty hours, leaving 
Wednesday and Saturday afternoons free for recreation, and for addi- 
tional drill and instruction for backward men. Instruction courses 
were also given in the evenings to the officers as a preparation for the 
following day's work. The work was divided as follows: 

First week, instruction twenty hours, athletic work and drill twenty 
hours. 

Second week, instruction twelve hours, athletic work and drill, 
twenty-eight hours. 

Third week, instruction sixteen hours, athletic work and drill twenty- 
four hours. 

Fourth week, instruction sixteen hours, athletic work and drill 
twenty-four hours. 

The athletic work consisted of foot ball scrimmages, wrestling, tug- 
of-war, jumping, hurdling and running over rough country. 

The efficient preparation and serving of proper food is no small 
factor in reaching a high state of physical efficiency, and to keep a 
command in good condition requires constant supervision of bowel and 
digestive functions by the medical officers. 

Perhaps the most important part of the training of a recruit is the 
acquirement of a subconscious habit of obedience and subordination to 
those in authority which is called military discipline. 






MOVEMENT OF TROOPS 525 

The very first paragraph in the Army Regulations reads " All persons 
in the military service are required to obey strictly and to execute 
promptly the lawful orders of their superiors." To quote from the 
Manual for Xon-Commissioned Officers, "Obedience is the first and 
last duty of a soldier. It is the foundation upon which all military 
efficiency is built, without it an army becomes a mob, while with it a 
mob ceases to be a mob and becomes possessed of much of the power 
of an organized force." 

The point for the hygienist to observe in this training is the fact that 
the soldier can also be handled so that he has the same subconscious 
obedience to hygienic principles as he observes toward other military 
subjects. The well instructed man covers his excreta at the latrine 
as a matter of course, and not because a sentry is stationed there to 
make him do it ; he also washes his hands before eating, keeps his food 
protected from flies, and avoids ice cold drinks, slops, trash, etc., when 
on the hike. 

It is the poorly trained man who causes the most trouble for the 
regimental surgeon. 

This thorough training of the soldier in the principles of hygiene, 
is of the greatest importance to the medical officer, who is responsible 
for the health of the organization to which he is attached, and is worth 
all the time he may spend to attain it. 

MOVEMENT OF TROOPS. 

Solcliers generally depend on marching especially during a campaign 
when it is necessary to move a command from one point to another. 
When long distances are to be covered, and transportation is available, 
railroads or boats are employed. "Marching constitutes the principal 
occupation of troops in campaign, and is one of the heaviest causes of 
loss. This loss may be materially reduced by proper training, and the 
proper conduct of the march." I. D. R. / 

Proper training consists in gradual hardening of the men and the 
thorough instillation of inarching discipline. 

Special attention should be paid to the fitting of shoes and the care 
of the feet. Regulations now provide that each man must be fitted 
with shoes in the presence of an officer, who is held responsible that the 
man is properly provided with suitable foot gear. 

The shoes should be of regulation army pattern, and of sufficient 
size to allow the foot to spread while carrying weight of equipment on 
long marches (hikes) . The feet, as a result of unaccustomed use, badly 
fitting shoes or socks, or through neglect, are liable to various injuries 
of which blisters, abrasions, bruises, sprains and corns are examples. 
These should all receive prompt attention, as a footsore army is of little 
use. During the recent campaign in Europe, considerable foot troubles 
occurred in the American units who served with the British Army, 
because they were not accustomed to the stiff shoes provided in that 
service, 



526 MILITARY HYGIENE 

The feet should be washed every day and clean socks put on, the pair 
taken off washed, dried and kneaded smooth to avoid wrinkles and 
rough spots. The feet may be soaped or dusted with talcum powder 
to lessen any friction before starting in the morning. A careful foot 
inspection by the company officers after each day's march will give 
wonderful aid in keeping up the efficiency of the command. 

F. S. R., I. S. A., provide that the rate of march of a mixed command 
is regulated by that of the foot troops; it varies with the length of the 
march, size of the command, condition of the troops and roads, weather, 
etc. 

For infantry, the rate prescribed for drill is 100 yards per minute, 
or 3.4 miles per hour. On the road the maximum to be counted on is 
80 yards per minute, or including halts about 2\ miles per hour: 

The average march of infantry or of mixed commands with foot 
troops is 15 miles per day, and in large bodies about 12 miles per day. 
Small commands of seasoned men, in cool weather and over good roads 
can average 20 miles per day. A maximum day's march for infantry 
and trains is about 28 to 30 miles, but this rate cannot be maintained. 
A uniform rate of march is of great importance, men tire very quickly 
with irregular gaits and rates of speed. 

To rest the men and animals, a command on the road is occasionally 
halted. The first halt is made after marching forty-five minutes and 
is fifteen minutes long to enable men to answer the calls of nature, 
adjust equipment, etc. After the first rest, there is for foot troops a 
halt of ten minutes every hour; that is, the troops march fifty minutes 
and halt ten. Places for halts should be selected with care, and should 
be made as much as possible outside of villages, towns, etc., so that 
their purpose may not be defeated. In very hot weather, the halts 
may be longer and more frequent. The men are allowed to fall out, 
generally on the right side of the road, leaving the other side clear for 
passage of vehicles, messengers, etc. They are required to remain in 
the immediate vicinity during the halt, and to resume their places in 
the ranks at the command "Fall In." 

As a rule, troops prefer to finish a day's march as soon as possible, 
hence, an early start is made, and lunches carried if the march will run 
well into the afternoon. A halt for one hour near meal time is advan- 
tageous. Portable kitchens that carry enough food for 250 men are 
sometimes provided; the meal is started before the march begins, and 
is cooked during the morning, so that when a noon halt is ordered, a 
hot dinner can be served. Fresh water to fill canteens, and for cooking 
purposes is also carried in water casks, this being essential in countries 
where water is scarce, or where the wells and streams have been 
poisoned by the retreating enemy. 

Precautions are taken to prevent excess in eating or drinking, especi- 
ally during a halt near a village or town. Canteens should be filled 
with water that is known to be safe before the men start, and with 
proper training a canteen of water should last one man for a day's 
inarch. Untrained troops drink at every opportunity, especially any- 



TRANSPORTATION BY RAIL 527 

thing in fluid form that is ice cold, the results of such practice being 
very soon evident. 

Soldiers should be trained to be economical in. the use of water, and 
to only use a very small quantity at a time while marching ; the dryness 
of throat and sensation of thirst can be controlled to a large extent by 
carrying a small pebble in the mouth to excite the flow of saliva; large 
draughts of water while giving relief for a time soon cause the man to 
become waterlogged. When canteens must be replenished during a 
inarch, it should be done by order, and the sources of the supply 
examined by experts before use. This applies particularly in countries 
where cholera is endemic. 

A source of great hardship on a march for foot troops is hot weather 
and dry dusty roads. Every precaution should be taken to prevent 
suffering from this cause. Green leaves or a moist handkerchief in 
the hat, opening the column in the middle so as to allow a current of 
air to pass down the center (foot troops march four abreast, a formation 
known as column of squads) and frequent halts in shady places are 
helps. 

When men are overheated care must be taken to prevent their being 
chilled by exposure to cold winds or draughts during halts. Xo men 
are allowed to leave the ranks without permission, it being the duty of 
all officers to prevent straggling. Marches are generally regulated 
when practical so as to arrive at destination two or three hours before 
dark to allow for making camp and preparing a meal before night. 

Xight marches are sometimes made in hot weather to avoid the heat 
of the sun, but they are usually due to military necessity. All night 
marches rapidly impair the efficiency of a command. Moonlight and 
good roads are favorable, and special effort is needed to maintain march 
discipline. 

During all marches, when it is necessary for a man to fall out on 
account of sickness or other cause, he is given a permit to do so. This 
is presented to the surgeon following in the rear of the column, who will 
direct him to the ambulance or care for him in other ways. 

TRANSPORTATION BY RAIL. 

Troops may be moved by rail over commercial or military railways. 
The former condition will obtain in all movements in time of peace, 
and for most concentration movements in time of war. In the theatre 
of military operations and along lines of communications, military 
railroads are used. Transportation is usually furnished at the rate of 
3 men to each section in tourist sleepers, or 3 men to each two seats 
in day coaches. When day coaches are used for a journey of over 
twenty-four hours' duration, an effort is made to provide an entire seat 
for each man. Trains of moderate size and good speed are preferred 
to long trains with low speed. Units are kept together with all their 
equipment, as much as possible, an officer accompanying each section. 
In the European campaign, most troop movements were made in ordi- 



528 MILITARY HYGIENE 

nary box cars, which held about forty men. There was more or less 
crowding and discomfort as the trains were heavy and very slow. 
Very little could be accomplished in the way of personal hygiene on 
these trips which lasted two or three days at a time, and advantage 
had to be taken of the frequent stops to allow the men to leave the cars 
for short periods of time. There were no toilet accommodations on 
these trains, and no water except what was carried in the canteens of 
the command. Some cooking was done by means of portable kitchens 
placed on flat cars. 

The medical officer is principally concerned before the troops entrain 
in seeing that the cars are clean, supplied with water and ice, and 
sufficiently lighted and heated. Urinals and closets must be in good 
condition and well supplied with water and toilet paper. 

The name of the organization and number of men allotted to each 
car should be plainly chalked on the side. Sentinels are placed at each 
door of the car to prevent the men from exposing themselves to danger 
by riding on platforms, jumping from trains during halts, etc. 

If it is desirable to exercise troops, they should leave the cars in a 
body under their officers. 

In journeys of more than twenty-four hours, kitchen cars are pro- 
vided, if possible; otherwise, baggage cars are fitted up with the usual 
stove used in camps. A car is used by two companies, each occupying 
one half. A heavy wooden box, about a foot deep is made which is 
lined with tin, this is fastened to the floor of the car and filled with 
sand, and on top of this a layer of brick; the stoves are put up on these 
boxes, the wood fires lying on the brick ; a stove pipe is carried up and 
out doors through the ventilator transom in the top of cars, ends of 
pipes turning toward rear of train to secure good draught. Enough 
wood is cut to last a few days and the provisions to be used are piled 
conveniently near, leaving a passage w 7 ay in the center, so as to be able 
to pass through the train, and not piling the material more than five 
feet in height to avoid its falling on those employed in the car during 
sudden movements of the train. 

For short trips, provision can be made to secure hot coffee and 
sandwiches along the route for the command. 

During the journey, the medical officer watches the sanitary condi- 
tion of the cars, the means provided for personal cleanliness, sleeping 
accommodations, and the manner of preparing and serving the food 
provided. The nature and quality of the food to be used should be 
looked after before the start is made, troops should always have several 
days' rations in advance to be used in emergencies. 

Trains are usually made up so that the kitchens are near the com- 
panies. A train for a battalion of four companies would be made up as 
follows, allowing each company three cars for the men: Locomotive, 
four freight cars (one for each company baggage), three tourist or 
sleeping cars, baggage car with kitchen for two companies; six tourist 
or sleeping cars, baggage car for two companies; three tourist or sleep- 
ing cars and car for officers at the rear. 



TRANSPORTATION BY WATER 529 

With such an arrangement, the men of each company can go directly 
to their kitchen car, without passing through the cars occupied by 
another unit. Men should remain seated during mess and the food 
brought to them directly from the kitchen cars by appropriate details 
large enough to serve all without undue delay. 

A medical officer and members of the sanitary detachment accom- 
pany each train, and provision is made to leave a few berths or 
sections in one of the cars for the care of any sick or injured. 

The senior line officer on the train is in charge and responsible that 
order is maintained. 

Special hospital trains are fitted up on each line of military railroad. 

TRANSPORTATION BY WATER. 

In estimating the transport capacity of ships it is customary to allow 
three to four gross tons per man and eight to ten per animal for ships 
of more than 5000 tons, and four to five per man, and ten to twelve 
per animal for smaller ships. This allowance includes rations, water, 
forage, etc., for the voyage and leaves a margin for reserve supplies. 

F. S. R. provides that if practicable, all transports carrying troops 
or animals shall be supplied with distilling apparatus adequate for the 
supply of water required, and as a reserve in case of emergency, a 
distilling ship furnished by the Navy shall, if practicable, accompany 
each convoy. 

An officer from the Navy controls the movements of the vessel, the 
commanding officer of the troops being responsible for the discipline 
and administration of his command. 

The problem confronting the medical officer on transports is the close 
crowding necessary, the berths for the men being arranged in tiers 
with very little room in between, and the crowded decks giving few 
chances for physical exercise. Early in the trip, and during storms, 
sea-sickness is a factor, and means must be taken to keep the troops' 
quarters free from vomited material. Ventilation and sanitary condi- 
tions of the sleeping quarters require close attention, and also daily 
inspection of the men to detect illness or vermin. 

The arrangements for feeding the men require close attention. 
During the late War, on account of submarine activity, ships had to 
run from dusk to dawn without lights; hence, many times on a crowded 
transport only two meals a day could be prepared and served during 
the daylight hours. 

The men should be divided into small companies and distributed 
over the ship so all can be fed at the same time. Provision should also 
be made for disposal of waste food left on plates and cleaning of mess 
kits. 

Special attention must be given to the water-closet accommodations 

on board, to see that they are kept well flushed and clean. Special 

egg-shape troughs, placed with large end down, are best for this purpose, 

as the contents are not so likely to be spilled out on the floor of the 

34 






530 MILITARY HYGIENE 

apartment with the rolling of the ship. When it is considered that we 
must allow about two men a minute to use these closets, this necessary 
care is obvious. 

The deck space must be so divided among the men that it can be 
utilized for programmes of enforced physical exercises during days of 
good weather. The frequent assembling of those on board to assigned 
places on the ship for emergency drills is also of importance. 

EQUIPMENT. 

During the movements of troops the things needed for their shelter, 
protection, food and comfort, have to be considered, and are usually 
the time factor in the general plan. It takes more time to take down, 
pack and load into trains or wagons, the tents, cots, stoves, rations, 
forage, etc., than it does to move the men. 

In actual campaign, the soldier carries much of his equipment with 
him, and this may weigh, including rifles, bayonet and ammunition, 
from forty to sixty pounds. Efforts have been made in the construc- 
tion of the 1910 pack to distribute the load over the body in such a 
manner that it can be most conveniently carried, and least impede 
the movements of the soldier, the old blanket roll and haversack having 
been generally discarded. During marches, when practicable, an effort 
is made by use of company wagons, to relieve the men of as much 
weight as possible, and in train or boat movements, only the necessary 
articles are taken on account of lack of space, the balance being packed 
and shipped. 

During battle the complete equipment is worn as much as possible, 
the pack furnishing considerable protection to troops against shrapnel 
when lying down. It was observed during battles in the late War 
that the men had a tendency in a fight to throw away everything that 
encumbered them so they would emerge from a two or three days' 
conflict with only torn clothes and a rifle left of their equipment. 

In addition to his arms, clothing, etc., each soldier carries a so-called 
"first aid packet" which consists of two sterile compresses and bandage 
placed in a hermetically sealed metal case, about two by four inches, 
with an arrangement for easy opening. Every man is supposed to 
know how to use and apply this first aid in case of emergency, and it is 
one of the duties of a medical officer to see that such instruction is 
given. 

SHELTER. 

At permanent posts or stations, the garrison is usually housed in 
wood or stone buildings called barracks, at concentration or mobiliza- 
tion camps, either in semi-permanent structures called cantonments, 
or under canvas, in the field under canvas and during campaign, 
long marches, or in the presence of the enemy, in so-called shelter tents 
or bivouac. 



SHELTER 531 

At a permanent post or station, the principles of hygiene are the 
same as would apply to any collection of buildings occupied by large 
numbers of men. These buildings are usually constructed with their 
purpose in view, and are supplied with water, light, heating facilities, 
etc., and the means for proper ventilation. 

The only problem presented to the medical officer outside of general 
sanitation, is to see that these appliances are maintained in effective 
condition, and that the unavoidable close contact of the inmates is 
closely watched to check the spread of any communicable disease 
which might be introduced into the community; for this reason, 
separate buildings for each organization are desirable. 

Plans and specifications used in construction of barracks for the 
U. S. Army, can be obtained from the Chief Supply Officer, U. S. Army. 
Buildings used as cantonments are usually of wooden construction and 
without the conveniences of those at permanent posts. The men are 
more likely to be crowded and the problem of general sanitation 
increased. Attention should be given to the mess-halls and kitchens, 
the places provided for laundry work, and excreta and garbage disposal. 

Mobilization camps, as their name implies, are used for the gathering 
of troops from different centers in time of war, and are always more or 
less congested. One of the serious problems to be met with by the 
medical officer in charge is epidemics of measles, mumps and other 
communicable diseases brought in by regiments composed largely of 
non-immunes from isolated districts. Concentration camps are used 
to collect bodies of troops together previous to embarkation for a 
foreign port, or entrance upon a campaign in proximity to the enemy. 
The men in these camps are more likely to be seasoned troops, and to 
have received their immunizing inoculations for typhoid and para- 
typhoid and also to have been successfully vaccinated. 

The medical officers' problem in these camps is usually one of general 
sanitation and to minimize the effects of crowding as much as possible. 

When an organization is under canvas in the field, the problem of 
water supply and effectual refuse, excreta and garbage disposal arise; 
also, the not less important factor of good food properly cooked and 
served. Most of the diarrhea and digestive disturbances of camp life 
can be traced to neglect of this subject. 

It is not a rare thing to visit a company kitchen and find the cereal 
burned or half cooked, the potatoes raw in the center, and the meat 
fried to a crisp and coated with grease. The cooking on the present 
stoves furnished in the army is limited to boiling, roasting, baking and 
frying, but most army cooks use frying to the exclusion of all others, 
and thus increase the indigestibility of the meals served. 

Tentage issued to organizations at the present time consists of the 
shelter or dog tents which are carried in the pack by the men and the 
larger pyramidal and wall tents used in more permanent camps. The 
pyramidal tent is issued in two sizes, the larger 16 feet square and 11 
feet high to top of roof, and the small 9 feet square, and 8 feet high to 



532 MILITARY HYGIENE 

top of roof. They are supported by a central pole resting upon a 
folding tripod, and held above by four chains hanging from a plate 
passed over the spindle of the pole. There is an opening in the top 
closed by a movable canvas hood operated by guy ropes from the out- 
side. During cold weather, when stoves are used in the tents, a hood 
of sheet iron is provided to prevent fire from an overheated stove pipe. 

The larger size tents are used for the men and will hold a squad 
(7 men and corporal) with cots for each man very comfortably; in a 
crowded camp, 15 to 30 men sleeping on the ground can be put into 
each tent, althought for sanitary reasons, such a course is not recom- 
mended. 

The small tents are used for officers, one or two occupying a tent. 
Wall tents are generally used by officers of the higher grades and are 
8J feet high and about 9 feet square, the advantage over the small 
pyramidals being that the tent is supported by a ridge and two end 
poles, the center of the tent being clear. An extra piece of canvas 
called a fly and fitted over any of these tents adds to comfort of the 
inmates by affording additional protection against extremes of heat and 
cold. 

All tents are made of extra heavy canvas and of a brown color, which 
protects the eyes from the glare of the sun, shades in with the land- 
scape and adds to the invisibility of the camp, and is a great improve- 
ment over the white tentage previously issued. The hospital tent is 
a wall tent of larger size, 11 feet high to ridge, and about 14 feet square. 
It accommodates five to eight cots. 

Shelter Tents. — Each enlisted man in heavy marching order carries 
as part of his equipment, one-half of a shelter tent. To pitch these 
tents, the command is formed in double rank, and a single tent made 
by the front and rear rank men buttoning their halves together. The 
tent is occupied by two men sleeping on the ground, each having a 
space 3 feet by 6 feet to lie on. 

The principles of hygiene to be observed regarding the tents them- 
selves are to keep the ground space occupied by the tent scrupulously 
clean and dry, to allow no food to be brought into the tents on account 
of insects, to see that proper ventilation is provided at night, and that 
the material of which the tent is constructed is kept clean and in good 
condition. Each clear day, tents should be furled by wrapping the 
canvas around the center pole, which is supported by the guy ropes 
attached to the hood, all contents of tent removed, and the ground 
space exposed to rays of the sun for some hours. On cloudy days or 
at other times the sides can be rolled up so as to give a good current of 
air through the tent. Ventilation is secured during sleeping hours by 
leaving the hood open on clear nights, and through the door which 
except in extreme weather should be left unfastened. In case of commu- 
nicable disease, the usual procedure has been to burn the tent. There 
is no reason, however, why a tent should not be soaked in a bichloride 
solution, and dried in the sun for purpose of effective disinfection. 



SELECTION OF CAMP SITES 533 



THE SELECTION OF CAMP SITES. 

Great care should be exercised in selecting a site. In general, the 
following principles govern : 

The site should be convenient to an abundant supply of pure water. 
Good roads should lead to the camp, and interior communications 
throughout the camp should be easy. Nearness to a main road is 
undesirable on account of dust and noise. Wood, grass, forage and 
supplies should be at hand or easily obtainable. 

The ground should accommodate the command without crowding 
and without compelling the troops of one unit to pass through the camp 
of another. 

The site should be sufficiently high and rolling to drain off storm 
water readily, and if the season be hot, to catch the breeze. In cold 
weather, it should preferably have a southern exposure with woods 
to the north to break the cold winds. In warm weather, an eastern 
exposure with the site moderately shaded by trees is desirable. The 
site should be dry. For this reason, porous soil covered with stout 
turf and underlaid by a sandy or gravelly sub-soil is best. A site on 
clay soil or where the ground water approaches the surface, is damp, 
cold and unhealthful. 

Alluvial soils, marshy ground, and ground near the base of hills, 
or near thick woods or dense vegetation are undesirable as camp 
sites on account of dampness. Ravines and depressions are likely to 
be unduly warm and to have insufficient or undesirable air currents. 

Proximity to marshes or stagnant water is undesirable on account of 
the dampness, mosquitoes and the diseases which the latter transmit. 
The high banks of lakes or large streams make desirable camp sites. 
Dry beds of streams should be avoided as they are subject to sudden 
freshet. 

The occupation of old camp sites is dangerous, since these are often 
permeated by elements of disease, which persist for considerable periods. 
Camp sites must be changed promptly when there is evidence of soil 
pollution or when epidemic disease threatens, but the need for frequent 
changes on this account may be a reflection on the sanitary adminis- 
tration of the camp. 

A change of camp site is often desirable in order to secure a change 
of surroundings, and to abandon areas which have become dusty and 
cut up. 

It is wonderful what can be done to change the aspect of a camp and 
to beautify the surroundings, by cutting out roads, the erection of 
fences, etc., by the soldiers themselves in a very short time. During 
an active campaign, tactical necessity leaves little choice in the selec- 
tion of camp sites, troops often having to spend considerable time in 
mud and water, exposed to the elements without protection of any kind. 



534 



MILITARY HYGIEKfi 



RATIONS. 

A ration in the army is the allowance of food for one man per day 
(three meals). 

There is no more important topic in military hygiene than the food 
of the soldier; nothing keeps the man in the army contented with his 
lot like a well-conducted mess. The components of the ration have 
been planned so that the essential quantities of proteids, fats and 
carbohydrates and an adequate number of calories are provided. 

The government usually allows from 26 to 75 cents per day, per man, 
for feeding the army, depending on the station and the prices of food 
in the locality. 

In the field there are three kinds of rations issued, namely, the 
Garrison ration, the Reserve ration, and the Field ration. The 
Garrison ration is intended for troops in garrison, camps, and wherever 
practical ; it is as follows : 



Component articles. 



Fresh beef . 



Quantities. 



20.00 oz. 



Articles that can be substituted. 
Fresh mutton, 20 oz. 
Bacon, 12 oz. 
Canned meat, 16 oz. 
Corned beef, 16 oz. 
Dried fish, 14 oz. 
Pickled fish, 18 oz. 
Canned fish, 16 oz. 
k Turkey (Christmas Day) 16 oz. 



Flour . . 



18.00 oz. 



Soft bread, 18 oz. 
Hard bread, 16 oz. 
Corn meal, 20 oz. 



Baking powder 
Beans . . ... 



0.08 oz. 
2.40 oz. 



Rice, 1 . 6 oz. 
Hominy, 1.6 oz. 



Potatoes 



20.00 oz. 



Potatoes, canned, 15 oz. 
Onions, equal quantity. 
Canned tomatoes, equal quantity. 
Other fresh vegetables, equal 
quantities. 



Prunes 



.28 oz. 



Dried apples, 1 . 28 oz. 
Dried peaches, 1 . 28 oz. 
Jam, 50 per cent, total issue. 



Coffee roasted and ground 1.12 oz. 

Sugar 3.20 oz. 

Milk, evaporated, unsweetened, 5 oz. 

Vinegar 0.16 gill 

Salt . 64 oz. 

Black pepper . . 0.04 oz. 

Cinnamon 0.014 oz. 

Lard 0.64 oz. 

Butter 0.5 oz. 

Syrup 0.32 gill 

Lemon extract . . . 0.014 gill 



Coffee roasted, not ground, 1 . 12 oz. 

Coffee, green, 1 . 4 oz. 

Tea, black or green, 0.32 oz. 



Pickles, equal quantity. 

Cloves, ginger or nutmeg, equal 
quantities. 



Oleomargarine, 0.5 oz. 
Vanilla, 0.014 gill. 



RATiOMS 535 

Quoting from Havard, "the fuel value in calories of the principal 
components is as follows : 

Fuel value, 
Component articles. Quantity in ounces. calories. 

Fresh beef 20. 1287 

Fresh mutton 20. 1440 

Bacon 12. 2040 

Dried fish 14. 276 

Pickled fish 18. 1029 

Canned fish . . ■ 16. 680 

Flour 18. 1828 

Soft bread 18. 1355 

Hard bread 16. 1712 

Corn meal 20. 1986 

Beans 2.4 228 

Rice 1.6 160 

Hominy . 1.6 172 

Potatoes 20.0 368 

Sugar 3.2 350 

Lard 0.64 160 

Butter 0.5 106 

Syrup 1.3 192 

By selecting the most nutritive articles such as bacon, hard bread, 
or corn meal, beans, potatoes, dried fruit, butter and syrup, we can 
obtain a maximum fuel value of 5378 calories, according to Langworthy, 
or 5674 carlories according to Wiley. 

On the other hand by using such articles as dried fish, soft bread, 
rice, potatoes and canned tomatoes and dried fruits, the fuel value can 
be reduced to 2500 calories. 

The average garrison ration habitually consisting of fresh' beef, 
bread, beans, potatoes and onions, dried fruit, butter, syrup and sugar 
or their equivalents, weighs 65 ounces, and contains 99 grams of fat, 
481 of carbohydrates and 157 of protein, with total fuel value of 
3536 calories." 

It has been found more economical for each unit of a regiment to 
provide its own mess. A company at war strength under the old 
system consisted of 150 men, and the field range was just about large 
enough to cook for this number. Under the French system with 
companies of 250 men, more heating surface and larger cooking utensils 
would be required. Some work has been done with fireless cookers 
and a battalion mess, the kitchen being on wheels, and the meal started 
before leaving camp and ready on halting, but with increased size of the 
units, this becomes impracticable, and the moving kitchen is more or 
less cumbersome, and likely to get stuck or lost on the road, and not 
be on hand when wanted. During the War with Germany, the rolling 
kitchen as used by the English Army, of a size sufficient to feed a com- 
pany of 250 men, was utilized by some of the American units with 
considerable satisfaction. 

The old system of individual cooking, where each soldier makes his 
own fire, and cooks his own meal, has been largely done away with, 
except in small scouting parties. It was wasteful of fuel, gave little 
or no variety of food, and the latter as a rule was badly cooked, and led 
to more or less digestive disturbances. 



536 MILITARY HYGIENE 

Each unit, at the present time, has a mess sergeant who is responsible 
for the drawing of rations and the daily menu. He has under him 
one or more cooks and several men detailed as kitchen police who assist 
in the preparation of the meals; the number of men working in the 
kitchen varies with the number of men in the organization to be 
served. 

The company kitchen should be visited by an officer daily, and the 
menu for that day inspected, and the sanitary condition of the place 
well looked after. An officer should also be present at the serving of 
each meal, to see that the food is properly cooked, that sufficient 
variety is observed, and that each man gets his proper proportion. 
There is a wonderful difference in the meals of the different companies 
of a regiment, some of the units living in splendid style with well- 
cooked food and abundant variety, while others will have the cereals 
burned, the meat spoiled or swimming in fat, and the whole meal as 
unsavory and unappetizing as can be imagined. The responsibility 
for the meals belongs to the commander of the company, and the man- 
ner in which his men are fed is an index of his ability. 

The medical officer is concerned with the kind of food served, and the 
manner of its preparation, the two factors being responsible for much 
of the digestive disturbances in the regiment; also the habits and 
personal cleanliness of those who prepare the food, and the fact that 
they may be carriers of some variety of disease. 

The means provided for the cleaning of the mess kits of the men, 
and the w T ay in which they are used, are sources of fruitful investiga- 
tion. Every man should be taught the importance of washing his 
hands before each meal. 

In hot weather, and where kitchens are not screened, the fly nuisance 
requires attention, and food has to be carefully watched and covered 
to avoid contamination. 

The kitchen, cooking utensils, ice-boxes, store rooms, etc., need the 
usual sanitary inspection at frequent unexpected intervals. 

The disposal of garbage and kitchen refuse will be taken up under 
another section, but it can be stated here that garbage is simply dis- 
carded food, and that if care is taken to provide proper well cooked 
meals and serve out the right size portion, the garbage problem will be 
much reduced, as the waste will be smaller. It is no uncommon thing 
in badly managed kitchens to find that the men throw away 50 to 75 
per cent, of the food served to them. 

When an organization is on the march during the day and halting 
at night, it is customary to provide two hot meals during the day, 
one in the morning before the start, and one at night after the halt, 
the soldier carrying a lunch provided in the morning which is eaten in 
the middle of the day. 

The Reserve Ration is the simplest efficient ration and constitutes 
the reserve carried for field service. It consists of: 

Bacon, 12 ounces. 

Hard bread, 16 ounces. 



DRINKING MATER 537 

Coffee, roasted and ground, 1.12 ounces. 

Sugar, 2.4 ounces. 

Salt, 16 ounces. 

Approximate weight 2 pounds. 

The Field Ration is the ration prescribed in orders by the commander 
of the field forces. It consists of the reserve ration in whole or in part, 
supplemented by articles requisitioned or purchased locally, or shipped 
from the rear. In campaign, a command carries as a part of its normal 
equipment, the following ration : 

(a) On each man, at least two days' reserve rations. 

(6) In the rations section of the field train for each man, two days' 
field and one day's reserve rations. 

(c) In the supply train, two days' field rations. 

In addition to the foregoing, commanders will require each man on 
the march to carry the unconsumed portion of the day's ration issued 
the night before for the noonday meal. 

Reserve rations are consumed only in case of extreme necessity, 
when other supplies are not available. They are not to be consumed 
or renewed without an express order from the officer in command of 
the troops who is responsible for the provision of supplies. Reserve 
rations consumed must be replaced at the first opportunity. 

Travel rations are issued in place of the ordinary ration when troops 
travel, otherwise than by marching, or when they are separated for a 
short time from cooking facilities and do not carry cooked rations. 
Sometimes when traveling, liquid coffee is provided at different train 
stops, and added to the cooked food carried. 

The emergency ration consists of a condensed or concentrated mix- 
ture of nutritious foods in a hermetically sealed tin. 

DRINKING WATER. 

(The principles of water purification, etc., are fully considered in 
another portion of this book.) 

A safe water supply is a necessity for the soldier, not only on account 
of the fact that it may be a medium for the transfer of pathogenic 
germs, but also to supply the needs of the body. 

F. S. R. gives as approximate daily requirements: 
1 gallon per man on the march. 

5 gallons per man in camp. 

6 to 10 gallons per animal on march or in camp. 

The above figures apply to water taken from streams, where animals 
are watered at the streams, and cooking water carried. In estimating 
the daily supply for permanent or semi-permanent camps, where water 
is piped to kitchens, bath-houses, etc., the requirements will be 25 to 
30 gallons per man and 10 to 15 gallons per animal, depending on 
climatic conditions. The quantity of water in streams may be esti- 
mated by the formula, B + D + V + 10.800 = gallons in twenty-four 
hours. 



53S MILITARY HYGIENE 

B=average width. D = average depth. V = average velocity (all 
in feet). 

I. 1). H. requires that immediately on making camp, a guard should 
be placed over the water supply. If the water be obtained from a 
stream, places should be designated for drawing water as follows: 
1 — For drinking and cooking. 
2 — For watering animals. 
3 — For bathing and washing clothing. 

The first named should be drawn furthest up the stream, the others 
in the order named down stream. If the stream is small, the supply 
may be increased by building a dam. Small springs may be dug out, 
and each cemented up or lined with a barrel or box with both ends 
removed, or with stones, the space between the lining and the earth 
being filled with puddled clay. A rim of clay should also be provided 
to keep out surface drainage. The same method may be used near 
swamps, streams or lakes to increase or clarify the water supply. 

Water that is not known to be pure should be boiled twenty minutes. 
It should then be cooled and aerated (to remove flat taste) by being 
poured from one clean container to another, care being taken to avoid 
contamination, or it may be purified by approved apparatus supplied 
for this purpose. Arrangements should be made for men to draw water 
from authorized receptacles by means of a spigot or other similar 
arrangement. The dipping of water from the receptacles or the use 
of a common drinking cup should be prohibited. 

The medical officer may assure himself of the safety of the source of 
the supply by the usual chemical and bacteriological tests, and by the 
more practical means of a sanitary survey, as the apparatus for the more 
complete methods are seldom available, and if they were, few medical 
officers in the army are trained in their use. In case only a small 
supply, as for a few men is needed, he can be reasonably sure in a friendly 
country by inquiring of the persons living near the stream or well as 
to the source of their own water supply. The average organization 
goes into camp laid out for it in advance with water piped to each 
company street, the purity of the supply being taken for granted 
because it is furnished that way. Unless the source of supply has been 
investigated by higher authority, the medical officer should assure 
himself of its purity as epidemics have been caused by neglect of such 
precautions. 

The medical officer in the field is often confronted with the problem 
of supplying his command with water from sources which are con- 
taminated, yet are the only supply available, and some simple method 
of making the water safe is needed. 

There are three methods at his disposal for this purpose, namely, 
heat, filtration and treatment with chemicals. 

Heating the water to the boiling-point is the surest and safest way 
of providing a safe article, but the method has many disadvantages. 
In the first place, it is almost impossible to so treat a supply sufficient 
for a large command ; there will be a lack of containers in which to boil 



bklU KING WATER 530 

the water, fires will not be made, the taste of the water is changed, 
odors come out more strongly on heating, and it takes a long time to 
get cool enough, especially during hot weather, to be palatable. Any 
method which will not supply an adequate supply of drinking water, 
within a short time after reaching camp will probably fail, as the men 
will usually drink anywhere in spite of the strictest supervision. On 
the other hand, if a march is to be continued the following day, it is 
very easy for each company to heat water on their fires after cooking 
supper sufficient to fill every canteen in the company with boiling water; 
the canteens are hung up over night, and a supply of sterile cool water 
for the march next day is provided ; if the water is made into weak tea 
or coffee the taste and color are changed, and the men accept the article 
more readily. 

Apparatus for the sterilization of water by heat is furnished of which 
the Forbes sterilizer is an example. Raw water enters a tube at one 
side, is exposed to heat furnished by an oil lamp with a vaporized flame, 
is partially cooled, and can furnish about 15 gallons per hour. The 
apparatus weighs about 100 pounds, and is 3| by 1 foot when packed, 
and requires one pint of oil per hour. Two barrels are needed, one for 
raw T water and the other for the sterile product. 

Filtration takes apparatus, either already made or improvised, and 
like boiling, takes considerable time for a sufficient supply of water 
to be provided, and it is not quite sure without suitable tests that all 
dangerous bacteria are eliminated. 

Several varieties of portable filters are provided, but all apparatus 
of this kind is open to the same objections, they take up considerable 
space, which must be considered in transportation, may get lost or 
not arrive with the troops, and may be out of order with no materials 
at hand to fix them. The Darnall filter can be taken as a specimen of 
the different types of mechanical filters, and is one of the simplest and 
least likely to get out of order. The apparatus consists of a galvanized 
iron tank, two water cans, a siphon filter and cloth, and a small hand 
pump to start the flow of water, the whole filtering into a crate about 
two by four feet, and weight about 10 pounds. The tank is filled with 
raw water to which a coagulant consisting of alum and sodium carbon- 
ate has been added. (5 grains of alum to the gallon, the proportion 
of alum and sodium carbonate being just sufficient to neutralize each 
other.) The cotton fibric used for filtering is fitted over the metal 
frame work of the syphon, and placed in the tank, and the water after 
passing through the filtering cloth into the cylinder is discharged by 
means of the syphon into the filtered water can. The cloth covers 
used for filters should be sterilized by boiling from time to time. 

If a camp is to be more or less permanent, regular filter beds can be 
built as is elsewhere described. An improvised filter for a small com- 
mand can be made by two barrels, one of smaller size and open at both 
ends, and setting inside of the larger one. The large barrel is filled to a 
depth of one foot with small stones, and the small barrel with perforated 
bottom, placed on the center of the stones, a foot of gravel is now added 



540 MILITARY HYGIENE 

on the outside over the stones and on top of this 12 or 14 inches of fine 
clean sand. Water is introduced on the outside of the small barrel, 
percolates through the layers of sand, gravel, etc., and fills the smaller 
barrel with a fairly pure water. Such a filter requires frequent cleaning 
and removal of top layers of sand. 

Pits can be constructed a few feet from the river's edge, where the 
soil is sandy, allowing the river water to percolate through the inter- 
vening space to fill them. The walls of such pits should be lined with 
clay or cement, and they should be protected from surface drainage. 

Chemical treatment of water for drinking purposes may be applied 
in several different ways, the simplest for army use being to have the 
chemical (hypochlorite of lime being the best) in small vials or tablet 
form, and of such strength that each vial or tablet will sterilize so 
many gallons of water. The Lyster bag used in the army holds 40 
gallons. A level teaspoonful of the chloride of lime is rubbed up well 
in a cup of water, which is further diluted by adding three cups of 
water, a teaspoonful of this last mixture will sterilize two gallons of 
raw w T ater with little apparent taste or odor. The dilution is about 
five parts of chlorin to a million parts of water. 



GENERAL SANITATION. 

Under the head of general sanitation, we will speak of sanitation as 
it affects the soldier and his environment, commencing with personal 
hygiene, the hygiene of the camp and trenches, and lastly the hygiene 
of the battle field. 

Personal Hygiene. — It is essential that the soldier should keep 
clean. In permanent camps, showers are usually provided, but during 
cold w T eather they are little used. Troops should be taught to wash 
the face, neck, feet, genital and axillary regions once a day with soap 
and water, and at least once each week to wash the entire body. The 
teeth should be cleaned with a good brush at least twice daily, and the 
mouth well rinsed out with clean water. Each soldier is supposed to 
keep himself clean, shaved and his hair kept neatly trimmed by the 
company barber. 

. Every man washes his own clothes, changes his underwear at least 
once a week, and as much oftener as may be needed. The company 
supply sergeant should see that the men are provided with enough 
socks and underw r ear to change as required. The uniform is kept 
repaired, clean, and pressed, and the shoes polished. 

In most camps except in the presence of the enemy, work and drills 
are suspended for two half days a week, and all day Sunday. This 
time the soldier has for his ow r n, so that his personal needs may receive 
attention. 

Every man should be instructed as to the functions of his digestive 
organs and regular bowel habits formed and continued. 

The formation of good moral habits is of great importance, and too 
much attention cannot be given to this side of a soldier's life. Men 



GENERAL SANITATION 541 

should be taught to report at once to the medical officer when ill, and 
not try to cure themselves. 

Camp hygiene resolves itself into the general sanitary conditions of 
the camp, the proper collection and disposal of refuse and garbage, 
and the treatment and disposal of human excreta. 

Under the head of refuse is considered all the debris of a camp, 
pieces of wood, papers, discarded clothing, tin cans, rubbish, etc. All 
this is collected several times a day by what is called policing the camp. 
Lines of men move slowly across the camp site, picking up everything 
that comes under this head, and collecting it in some central place 
where it is burned. Tin cans are well burned in the fire, then flattened 
out with a mallet so they will not hold water, and carted to some desig- 
nated place with other rubbish that cannot be destroyed by fire and 
then buried. 

The ground around the corral where horses, mules and cattle are kept 
is cleaned twice daily, the surface burnt over with oil to destroy flies, 
and the sweepings either burned or removed to some place outside the 
camp limits, which is set aside for this purpose. 

Garbage and kitchen refuse, both liquid and solid, require constant 
attention. Reference has been made elsewhere to the fact that this 
problem can be considerably lightened by proper attention to the 
preparation and serving of food, so there will be little or no waste. 

The liquid slops from the kitchen, water from dishwashing, and the 
soapy water from laundries #nd baths is the hardest to dispose of. 
In sandy soils, they can be conducted to dry cesspools and thus disposed 
of but where the soil is impervious, some method of destruction by 
fire must be resorted to. The solid garbage can either be collected in 
cans and removed daily by contract with local farmers who use it for 
feed, manure, etc., or it can be burned. Simple devices can be con- 
structed for this purpose, and every mess should care for its own 
garbage. 

Most of the improvised crematories are constructed by heaping rocks 
in different shapes, sometimes flat, sometimes in a pit with a heap of 
stones in the center to serve as a chimney. A fire is built on these 
rocks and the solid garbage directly consumed, when the rocks get hot, 
the liquid slops are slowly poured on and turned into steam by contact 
with the hot surface. 

This method requires constant attention and is wasteful of fuel; 
moreover, it must be thoroughly cleaned and reconstructed at frequent 
intervals. Another crematory has been made in which a pan is placed 
over the flames, and the liquid slops evaporated in this way, while the 
solid portions are burned underneath. This fire can also be used to 
heat water for the cleansing of mess kits, etc. Regularly constructed 
crematories for the destruction of garbage from cities and large camps 
will be described elsewhere. 

The Disposal .of Human Excreta. — For a large permanent camp, a 
regular sewer system should be planned with some means of treatment 
of the waste matter, as is described in other places, 



542 MILITARY HYGIENE 

Where troops are marching and halting for a few days, I. D. R. 
provides that immediately on arriving in camp sinks should be dug. 
This is a matter of fundamental sanitary importance, since the most 
serious epidemics of camp diseases are spread from human excreta. 

One sink is usually provided for each company, and one for the officers 
of each battalion. Those for the men are invariably located on the 
side of the camp opposite the kitchens. All sinks should be so placed 
that they cannot pollute the water supply or camp site as a result of 
drainage or overflow. To insure this, their location and distance from 
camp may be varied. 

When camp is made for a single night, shallow trenches 12 inches 
deep, and 15 to 18 inches wide, which the men may straddle, will 
suffice. 

In more permanent camps, the trenches should be about 2 feet wide, 
6 feet deep, and 15 feet long. They should be provided with seats and 
back rests made of poles, and should be screened by brush or old tent 
flies. In cold weather the contents of sinks should be covered once 
daily with quicklime, ashes or dry earth. When filled to within two 
feet of the top, sinks should be discontinued and filled in. 

Open pits are dangerous during the fly season. However, this dan- 
ger may be greatly reduced by covering the excreta with earth or by a 
thorough daily burning of the entire area of the trench. Combustible 
sweepings or straw saturated with oil may be used for this purpose. 

In fly season trenches may be closed with seats, covered down to the 
ground with muslin and supplied with self closing lids. Urinal troughs 
made of muslin and coated with oil or paint should discharge into the 
trenches. Urinal tubs or cans are placed in the company streets at 
night to prevent the pollution of the adjoining ground which would 
otherwise happen. They are removed at reveille. Their location 
should be marked with a lantern, and the soil under and around them 
thoroughly and frequently disinfected. When troops bivouac for the 
night, the necessity for extensive sanitary precautions is not great. 
However, shallow sink trenches should be dug to prevent general 
pollution of the vicinity. If the cooking be collective, shallow kitchen 
sinks should be dug. If the cooking is individual, the men should be 
required to build their fires on the leeward flank of the camp or bivouac. 

Before marching, all trenches should be filled in, and the camp site 
well policed. 

In camps more or less permanent, boxed latrines are used and have 
been found to answer every purpose. A trench 10 to 12 feet long, by 
2 or 3 feet wide, and G to 8 feet deep is dug. Over this a fly proof box 
of suitable size is built, with an appropriate number of seats, each fitted 
with a self-closing lid. The space between the bottom of the box and 
the ground is well banked up to exclude surface water and flies. Any 
cracks or knot holes in the lumber are covered over. One such latrine 
is built for each company of the organization at a place selected by the 
medical officer. The box is turned back once daily, the seats and top 
scrubbed with soap and water, and straw saturated with oil burnt in 



HYGIENE OF GAS ATTACKS 543 

the pit, or else the entire surface of the pit and inside of the box is 
sprayed with kerosene and lampblack, by a detail from the sanitary 
corps. 

A funnel with a strainer at the bottom is connected with a trapped 
pipe leading to the trench and is used as a urinal. This is also cleaned 
and oiled daily. 

Efforts have been made to destroy all excreta in specially devised 
incinerators, of which the McCall is a type. The objection to these 
is the weight and difficulty of transportation, and the quantity of fuel 
or oil needed for the combustion. 

Toilet paper in rolls, placed in boxes to protect it from the weather, 
should be furnished, and care observed that loose portions should not 
be scattered around the latrines or blown over the camp site. 

Trenches. — When trenches are constructed for more or less per- 
manent occupation, provisions for drainage must be observed, and also 
means provided to prevent surface water running into them. The 
problem presented depends entirely on the location of the trench, and 
the nature of the soil. As trenches are constructed as a military neces- 
sity, with little regard for hygienic principles, the situation at times is 
very discouraging to the medical officer. It is not unusual for the men 
occupying trenches in low ground to be waist deep in water during 
heavy rains. Efforts are made during construction, however, to slope 
the floor of the trench so that water will run along the rear to dry cess- 
pools, or be disposed of by under-drains or sumps to some suitable 
place that may offer. 

Latrines are placed in the angles of communicating trenches, so they 
may be readily reached by the men. The pail system answers best for 
this purpose. When men are required to live for some time in dug- 
outs, which are at least 20 to 35 feet deep, almost all sanitation is 
sacrificed to secure protection from the fire of the enemy. The air is 
apt to become close and foul, and the only thing that can be done is 
to make the stay of each unit as short as possible in such location. 
They are usually constructed with a tier of wooden bunks on each side 
on which the men rest. Periscopes are also used as ventilators. 



HYGIENE OF GAS ATTACKS. 

Modern warfare has recently utilized different varieties of gas as a 
means of offense and defense. 

The first use of such a weapon was in an attack on April 22, 1915, 
by the Germans at Ypres, on a sector of trench occupied by French and 
Canadian soldiers; the number of casualties was enormous. 

Gas is used in the form of a cloud, which a favorable wind will carry 
toward the enemy after it has been released from its liquid form in 
cylinders buried under the trenches, or by means of gas shells which 
explode within the enemy's line and scatter the liquefied gas. The 
heavier gases are utilized on account of slow diffusion. They are 



:>11 MILITARY HYGIENE 

roughly divided into three groups, according to their effect on the 
human body as follows: 

(a) Lachrymatory. 

(b) Asphyxiating. 

(c) Paralyzant. 

A great variety of acids may be used for the production of gases, 
and chemists in all armies are constantly experimenting with a view to 
successfully combating their use, and perfecting new and more potent 
combinations. The ones most commonly used at present for the suf- 
focating and lachrymatory group are combinations of benzol and ace- 
tone with chlorine and bromine. 

The deadly character of gas attacks can be almost entirely obviated 
if the proper measures of protection are known and strictly enforced. 
This implies a familiarity with the different varieties of gas masks used, 
the principle of all being the fact that the inspired air is drawn through 
different layers of chemicals in the bottom of the mask which neutra- 
lize or absorb the dangerous gas. Effectual means of sounding the 
alarm, when a gas attack is impending are also important. Some gases, 
as carbon monoxide are colorless, odorless and tasteless. During an 
attack, the command is kept as quiet as the military situation will 
allow, all marching ceases within an area of three miles, and all within 
this limit wear and use their masks. Wounded men are watched to 
see that they do not tear their masks off. 

The only way in which dug-outs and cellars can be cleared of gas is 
through ventilation by means of fires and gas fans. A sprayer has 
been used with an alkaline solution which neutralized chlorine, but with 
the advent of other gases, its efficiency was lost, and it is now only 
useful in wetting the blankets which hang at each dug-out entrance as a 
protection against the entrance of gas. 

The defenses used against gas attacks in our army are under 
the direction of the medical department, and it is charged with the 
duty of providing gas masks, resuscitation apparatus, etc. The 
chemicals through which the poisoned air is inspired must be renewed 
from time to time, according to. their use. Most masks can be used 
from twelve to seventeen hours continuously without recharging. The 
men must be well drilled in the use and adjustment of the masks. 
They are supposed to be put on within six seconds by each individual. 

The hygiene of the battle field may be divided into two portions; 
first, the precautions which the individual may take before going into 
action, and later, the removal and care of the wounded and disposal of 
the dead. 

Each soldier, if possible, before going into battle, should be as clean 
as possible both in body and clothing, to prevent possible infection if 
wounded. His bowels and bladder should be empty, and he should be 
sure to have his canteen filled with good water, and be provided with 
a first aid packet. 

If seriously wounded, he will do better to remain where he fell until 
picked up by litter bearers, than to try and reach help himself, and 



THE PHYSICIAX IN THE ARMY o±o 

perhaps aggravate his injury. Unless the battle line is at a halt, lie 
cannot expect much help from his surrounding comrades, except 
perhaps to bandage him up and leave him in a comfortable position. 

I. D. R. states that " when officers or men belonging to fighting troops 
leave their proper places to carry back or to care for wounded during 
the progress of the action, they are guilty of skulking. This offense 
must be repressed with the utmost vigor." 

With the above in mind the necessity of each man being provided 
with a first-aid packet and the knowledge of its proper use is apparent. 
First aid stations are established by the medical corps as close to the 
firing line as possible, and are advanced as that line progresses. The 
duties of this department become more arduous as the battle closes, 
for on them rests the responsibility for the removal of the wounded 
and the sanitary control of the battle field. 

The dead are collected by details of troops and disposed of by burial, 
or otherwise, as the commander may direct. Large numbers of dead 
animals, as horses and mules, may also have to be disposed of by fire 
or burial. F. S. R. provides that no body shall be buried or otherwise 
disposed of until identified if such is possible. 

Before a command enters upon a campaign, every member thereof 
is provided with an identification tag, by which he can be identified 
if killed or wounded. These tags are made of aluminum with the man's 
name stamped on them, and are worn suspended around the neck. 
Such tags are not removed from the dead but are left on the bodies 
when interred or otherwise disposed of. Tags found on the bodies of 
the enemy's dead are collected and turned over to the commander of 
trains who send them to the provost marshal at the base. 

THE PHYSICIAN IN THE ARMY. 

Medical officers were formerly called surgeons, but as our knowledge 
of hygiene has advanced the great importance of this subject to an 
army has been recognized, and at the present time, the practice 
of surgery is usually confined to the base and field hospitals ; the 
medical officer who accompanies the troops does little of this work, 
simply giving first aid, meeting emergencies, and passing his patient 
on to the place provided. He is now primarily a sanitarian, and the 
greater part of his work runs along the lines of hygiene, sanitary 
science and preventive medicine. 

The medical officers of today have a recognized rank. They gen- 
erally enter the service as first lieutenants, and gradually rise through 
the grades of captain, major, lieutenant-colonel and colonel, and he 
may become the surgeon general. His rank corresponds with that of 
the officers of the line and staff, but he does not command troops out- 
side of the sanitary detachment. 

Medical officers are generally attached at the rate of four to a regi- 
ment of 2002 (old tables of organization). In addition ambulance 
companies, field and base hospitals are organized and manned by the 
35 



546 MILITARY HYGIENE 

medical department. Dental surgeons are now attached to the sani- 
tary corps, and the teeth of the men are well looked after. Frequent 
inspections of the command should be made to detect diseased teeth. 
F. S. R. defines the duties of the sanitary service in the field as follows : 

1. The institution of all practicable sanitary measures to the end 
that the fighting forces surfer no depletion in strength due to avoidable 
causes. 

2. The temporary care and professional treatment of the sick and 
wounded and their transportation to accessible points, where they are 
transferred with as little delay as possible to the line of communication. 

3. The supply of the necessary sanitary equipment. In addition the 
sanitary service is charged with the preparation and preservation of 
individual records of sickness and injury in order that claims may be 
adjudicated with justice to the government and the individual. 

The personnel of the sanitary service in the zone of the advance may 
be classified into two general groups. First, that attached to organiza- 
tions smaller than a brigade which functions under the immediate orders 
of the organization commander and accompanies its units into combat. 
Second, that attached to the sanitary train which functions under the 
orders of the division surgeon in accordance with such general or 
specific instructions as he may receive from the division commander. 

When necessary, the sanitary personnel attached to organizations 
may be temporarily detached in whole or part, and directed to operate 
with the sanitary train. 

Sanitary officers and men of all arms must have a knowledge of sani- 
tation and its importance to the end that no depletion of the fighting 
force occur through avoidable causes. The importance of adopting and 
carrying out proper sanitary measures cannot be overestimated. 

Commanders of all grades are responsible for the sanitary condition 
of the quarters or localities occupied by their commands, and for the 
enforcement of all sanitary regulations. In addition, they are respon- 
sible that all sanitary defects reported to them are promptly corrected. 

A medical officer of experience designated sanitary inspector is 
charged under direction of the division surgeon with investigating and 
reporting upon the sanitation of the division, to which he is attached. 
Sanitary inspectors report the result of their inspections to local com- 
manders, as well as to the division surgeon. 

First-aid Packet. — Every man with the division carries a first-aid 
packet. The sanitary detachments with organizations carry pouches 
containing appliances for first aid and stimulants. The combat train 
carries litters and the necessary equipment for regimental aid station. 

Regimental Aid Station. — This station established by each regiment 
or independent battalion during combat, and when justified by the 
number of wounded, is the place to which all wounded of the organiza- 
tion are carried by its sanitary personnel, and where emergency treat- 
ment is administered. The position of the station is fixed by the organi- 
zation commander, and is as near the firing line as possible. This 
station will often be but little more than a place for assembling the 



THE PHYSICIAN IN THE ARMY 547 

wounded, as its personnel belongs to the organization and therefore 
must be prepared to move with it. After receiving emergency treat- 
ment all wounded, able to walk (except those with trivial wounds who 
are sent back to the line) are directed to the station for slightly 
wounded; those unable to walk are delivered to the bearers sent for- 
ward from the sanitary train. 

The equipment of the regimental aid station is carried on the combat 
train. It is operated by the sanitary personnel of the organization. 

Dressing Stations. — These stations established during combat 
by ambulance companies of the sanitary train in the immediate rear 
of the line of regimental aid stations, are the places where all wounded, 
unable to walk, are collected from regimental aid stations by bearers 
of ambulance companies. If conditions so warrant, these bearers 
may be assisted in their work by portions of the organization sanitary 
personnel. From these stations the wounded are transported by ambu- 
lance companies back to field hospitals. 

The equipment for dressing stations is more elaborate than that of 
the regimental aid station. It provides light nourishment and stimu- 
lants for the wounded, and affords facilities for more elaborate dress- 
ings and for emergency surgery. The equipment for dressing stations 
and the necessary personnel are supplied by the ambulance companies 
of the sanitary train. 

Ambulance Companies. — Ambulance companies push up close to 
the rear of the fighting troops and as near the line of regimental aid 
stations as possible, and establish dressing stations. In addition to 
their functions at the dressing stations, the}' are charged with the 
transportation of the wounded back to field hospitals, and with provid- 
ing the necessary equipment for infirmary service in camps. When 
field hospitals have not been set up and when sanitary columns or 
railway hospital trains of the line of communications are reasonably 
accessible, ambulance companies transport the wounded directly to 
them. 

Field Hospital Companies. — Field Hospital companies form part 
of the sanitary train. They are set up when conditions so warrant, 
ordinarily some three or four miles from the battle field, and are the 
places to which the wounded are transported by ambulance companies. 
Their position must be one accessible both from the front and rear, 
and where good water is available. Field hospitals are not set up when 
the sick or wounded can be turned over conveniently to elements of 
the sanitary column or railway hospital trains of the line of communica- 
tions. Canvas is pitched, only when buildings are not available or are 
inadequate for the purpose of housing the wounded. 

The equipment of the field hospitals, while more elaborate than that 
of dressing stations, and while providing canvas for protection of the 
wounded from the weather, and facilities for more extended surgical 
work, is nevertheless limited to providing necessities for the sick and 
wounded, pending the evacuation to the rear by the line of communica- 
tions, 



548 MILITARY HYGIENE 

Evacuation Points. — The sanitary column of the line of communi- 
cations includes ambulance companies and evacuation hospitals; there 
also may be available railway hospital trains and boats, any or all of 
which may be used as the means for the evacuation of the sick and 
wounded from the division. The places at which the sick and wounded 
are transferred from the division to the line of communication elements 
are termed evacuating points. The position of evacuating points are 
fixed in the same manner as is the refilling points of the supply service 
(by division commanders), and communicated directly from division 
headquarters to the commander of the sanitary train. 

Stations for Slightly Wounded. — A station for slightly wounded is 
established when combat is imminent, to relieve dressing stations and 
field hospitals of the slightly wounded who can walk, and require but 
little attention. Its position is fixed in division orders. It is operated 
by the personnel of the sanitary train detailed for the purpose. It is 
conspicuously marked so that it can be readily found. 

The Sanitary Train. — The sanitary train is composed of ambulance 
companies, field hospital companies and camp infirmaries. The 
sanitary train is commanded by the division surgeon (lieutenant- 
colonel) or, in his absence, by the senior medical officer of the attached 
elements, who, upon its release from the control of the commander 
of trains operates it in accordance with orders or instructions received 
from division headquarters. 

Service in Camps. — In camps an ambulance service is furnished 
from the sanitary train. Infirmaries are set up at convenient points 
by order of the division surgeon, and operated by the sanitary personnel 
attached to the organization which the infirmary serves. Here cases 
not requiring hospital treatment are cared for, all other cases being 
promptly removed by the ambulance service. The senior medical 
officer of the units served by the infirmary, assumes charge of the same, 
and is authorized to call directly on the other organizations for their 
proportionate share of medical officers and sanitary personnel for the 
infirmary service. The sergeant, hospital corps, detailed with the 
infirmary, remains with it in charge of the equipment. If necessary, 
field hospitals are set up for the reception of the seriously sick or 
wounded. 

Service on the March. — When out of the presence of the enemy, 
ambulances are ordinarily ordered distributed by the division com- 
mander throughout the column, in the rear of regiments, battalions, 
etc. A camp infirmary is assigned to each brigade, and marches in 
its rear, and a field hospital should be so located in the column of march 
as to permit of its being available for the reception of seriously sick 
and injured, as soon as possible after the arrival of troops in camp. 

During marches in the presence of the enemy, ambulance companies 
are kept intact. It may be advisable to assign one or more of these 
companies to a position in the column of the combatant troops, but 
any further dispersion is inadvisable. When combat is imminent, 
and when so ordered by the column commander, the ambulance com- 






THE PHYSICIAN IN THE ARMY 549 

panics fall out of the column, and as soon as the combatant troops 
have passed, they take a position assigned in the rear. 

A man falling out from sickness or injury, is sent with a pass showing 
his name, company and regiment or corps, to the medical officer in the 
rear. The latter returns the pass, having indicated thereon the dis- 
position made of the man. If the man is unable to walk, he is picked 
up by the first ambulance and cared for. If able to walk, he may either 
be required to follow immediately behind his organization or ordered 
to await the arrival of the sanitary train. In the latter case he is 
furnished with a tag, showing the orders given him. 

The arms, personal equipment and clothing of soldiers who fall out 
are carried with them. 

The horse, saber and horse equipment of a mounted soldier admitted 
to the ambulance or otherwise disposed of, are taken back to the troops 
by the non-commissioned officer that accompanied him. 

Service in Combat. — In the absence of medical assistance the 
wounded apply their first-aid packets, if practicable. With this excep- 
tion the care of the wounded devolves upon the sanitary troops, and 
no combatant unless duly authorized is permitted to take or accompany 
the sick or injured to the rear. The sanitary personnel of organizations 
must remain with it when advancing into action, and during the whole 
course of an engagement. Accordingly, the wounded w T ill be treated 
where their wounds are received, and the sanitary personnel will pause 
if the organization is moving, only so long as is necessary to give appro- 
priate first aid. At a later stage of the combat, when the movement of 
the organization permits, and when justified by the number of wounded, 
a regimental aid station is established and operated. When combat 
is imminent, the station for slightly wounded is announced in division 
orders, and thereafter it is to this station that all disabled men able to 
walk are ordered to report. They are furnished with a tag, showing 
the orders given them by the medical officers, authorizing their proceed- 
ing to this station. 

The evacuation of the wounded from regimental aid stations when 
established, and the evacuation of the wounded left by the organiza- 
tions during an advance, when a regimental aid station has not been 
established, devolves on the personnel of the sanitary train. 

In the case of a deliberate attack on the enemy in position, or when 
our forces occupy a defensive position, the positions of dressing stations 
are fixed in orders by the division commander, and communicated to 
the troops. The division commander in this case advises the comman- 
der of the sanitary train, as to the position of the field hospitals. In 
the -case of an unexpected engagement, the work of establishing dressing- 
stations, field hospitals, and of evacuating wounded during combat 
from the dressing stations to the field hospital, or in certain cases 
directly to the line of communications, must be left to a great extent 
to the initiative and judgment of the commander of the sanitary train 
and his subordinates. 

To this end, the commander of the sanitary train sends forward one 



550 MILITARY HYGIENE 

or more ambulance companies, to make contact in certain prescribed 
areas with the sanitary formations of the combatant units. When 
ambulance companies have been assigned positions in the column of 
inarch of combatant troops, they are usually utilized in this work. 
The remaining ambulance companies ordinarily accompanied by one 
field hospital, and under the immediate command of the sanitary train 
commander follow, and are held together in reserve at a certain pre- 
arranged position selected by the sanitary train commander, and by 
him communicated to the commander of the ambulance companies 
sent ahead. The other field hospitals remain for the time being under 
the control of the commander of trains, to be brought forward later if 
required. The ambulance company commanders ordered to make 
contact with the combatant organizations push forward agents for the 
purpose of sanitary reconnaissance, and for arranging for the position 
of the dressing stations, and for determining the best line of approach 
to them. 

When so ordered they establish dressing stations and commence 
collecting wounded from the different regimental aid stations, ulti- 
mately sending them back to the field hospital at the prearranged 
point. 

The commander of the sanitary train keeps himself advised by means 
of agents of the progress and development of the battle and the number 
of casualties in certain areas, and from these reports, and from orders 
received from the division surgeon, he pushes forward additional 
ambulance companies when required, prescribing the area of their 
respective activity, and the point to which their wounded are to be 
transported. At the same time he may order forward such additional 
field hospitals as may be required. 

Search for Wounded. — After an engagement, commanders organize 
a thorough search of the battle field in their vicinity for the wounded, 
and assist in their protection and removal. The dead are collected 
by details from the line as soon as practicable after the battle and 
disposed of as the commander directs. 

Retreat. — In a retreat such portion of the sanitary personnel of the 
division as is required, will remain with the sick and wounded that 
cannot be moved, under the protection of the Red Cross flag. 

American National Red Cross Association. — The service of the 
association, its equipment and personnel are utilized under the imme- 
diate direction of medical officers, to the greatest extent possible in the 
care of the sick and wounded in the service of the interior, and in the 
line of communications. Their services are not utilized in the zone of 
the advance. 

Badge of Neutrality. — The emblem of neutrality is a red cross on a 
white ground. All persons belonging to the sanitary service, including 
the red cross association personnel and chaplains attached to the army, 
wear on the left arm, a brassard bearing this emblem stamped by 
competent authority. 

Those not uniformed carry a certificate of identity, in addition to 



DISEASES OF THE SOLDIER 55l 

the brassard. All sanitary formations and establishments display a 
Red Cross flag, accompanied by the national flag. 

At night the positions of sanitary formations are marked by green 
lanterns. 

DISEASES OF THE SOLDIER. 

There is nothing peculiar in the diseases of the soldier. As would 
be inferred, he is most subject to those infections, which are spread by 
close contact, and which can be conveyed through food and drink. 
Bowel inflammation; dysentery, typhoid and paratyphoid, are types 
of such infection. The American soldier at the present time is inocu- 
lated against typhoid and paratyphoid and is properly vaccinated. 
Some work has also been done along the lines of protective inoculation 
against pneumonia. 

Common colds and sore-throats are often prevalent during spells 
of bad weather, due to exposure and close crowded tents. Diseases 
of the respiratory tract, bronchitis, pneumonia, influenza and tubercu- 
losis are not uncommon. Tuberculosis is usually due to the breaking 
down of some old undiscovered lesions, from hardship and exposure. 

The common communicable diseases as mumps, measles, meningitis, 
scarlatina, etc., often break out among troops from suburban districts, 
and spread rapidly in a crowded camp. An army stationed in any 
locality, must be guarded against the particular diseases of that loca- 
tion, as hookworm, dengue, yellow fever, etc., in the south; scurvy, 
frost bite, etc., in the far north; and cholera, typhus and plague in the 
countries where they are endemic. 

The protection to be provided for the soldier is the same as has been 
described elsewhere for the civilian. 

Skin diseases, pediculi and scabies are sometimes found in camps 
where personal hygiene is not strictly observed ; cases of Rhus poisoning 
are not uncommon among fresh arrivals in a camp. Mental disturb- 
ances are of frequent occurrence in camps of mobilization, running 
from hysteria to melancholia. These are more often seen when troops 
are not kept fully employed. 

Communicable diseases and those transmitted by contact are quickly 
checked by dividing the command into small isolated units with no 
communication between them, and at the same time observing such 
other precautions as are generally taken for the control of such infec- 
tions. 

On foreign service, diseases of nutrition as beriberi, etc., are to be 
guarded against. 

Alcoholism and venereal diseases are sometimes prevalent in camps 
situated near towns or cities where liquor is easily obtained and the 
population is of low moral tone. 

The passage of the law forbidding the selling of any kind of drink 
containing alcohol to a soldier, during the war with Germany, has 
made a great difference in the morbidity records of the American Army. 



552 MILITARY HYGIENE 

SCHEME FOR THE SANITARY SURVEY OF A CAMP. 

Location. 

Nature of surrounding terrain. 

Direction of drainage. 

Presence of marsh land, water, trees. 

Pollution of water supply. 

Direction of prevailing winds. 

Proximity of dusty roads. 

Accessibility, distance to railroad. 

Mosquitoes. 

Population. 

Places of low moral character. 

Presence of dangerous animals or reptiles. 

Poisonous plants. 

Camp. 
Number of men. 
Kind of shelter provided. 
Number in tent. 
Arrangement for drainage. 
Condition of canvas. 
How frequently are tents furled? 
Condition ofjnterior. 
Sleeping arrangements (cots or ground). 
Are the bed sacks filled with straw ? 
Condition of blankets and clothing (quantity per man). 
Food in tent? 
Mosquito bars. 
Arrangements for heating. 
Presence of illness. 
Refuse disposal. 
Camp roads and streets, drainage, cleanliness, dust. 

Kitchens. 
Water supply. 
Provision for drainage. 
Disposition of kitchen slops, garbage. 
Firewood. 
Stoves. 
Store rooms. 
Ice-box. 

Protection for food (raw T and cooked) . 
Kitchen enclosed (dust). 
Presence of flies. 

Cleanliness of interior and utensils. 
Distance to latrines. 






SCHEME FOR THE SANITARY SURVEY OF A CAMP 553 

Number of men in kitchen, cleanliness, white suits, possible disease 

carriers. 
Incinerators. 
Garbage barrels. 

Mess Halls. 

Number accommodated. 

Manner of serving food. 

Waiters. 

Cleanliness. 

Table covering. 

Light, heat, ventilation. 

Flies. 

Water Supply. 
Source. 

Precautions to insure purity. 
Possible chances of contamination. 
Is it boiled before using? 

Food Supply. 
Source. 

Meat inspected. 
Milk inspected. 
Cooking. 
Variety. 
Waste. 

Care of before and after cooking. 
Canned goods. 
Ice. 

Food handlers. 
Regularity of meals. 
Well balanced ration. 

Latrines. 
Number. 
Position in camp. 
Size. 
Variety. 

Precautions taken to exclude flies. 
Cleanliness. 
Odor. 

Toilet paper. 
Privacy. 
Urinals. 

Number of men accommodated (size of command). 
Precautions against surface drainage. 
Contamination of any water supply. 
Are disinfectants used? 
Urinals in company streets at night. 



554 MILITARY HYGIENE 

Corral. 

How many and kind of animals kept? 

Condition. 

Cleanliness. 

Manure disposal. 

Water supply. 

Forage. 

Shelter. 

Personnel. 
Uniforms and equipment. 
Personal hygiene. 
Presence of illness. 
Prophylactic inoculations. 
Vaccination. 

Extra underwear, socks, clothing. 
Shoes, condition, fit, extra pair. 
Condition of feet, hair, head and teeth. 
Condition of canteen and mess kits. 
Percentage of new men. 
Daily routine. 
Number of medical officers. 
Facilities for care of sick. 
Canteen, character of articles sold. 



CHAPTER XXII. 

RURAL PUBLIC HEALTH WORK. 

By FRANK OVERTON, M.D, D.P.H., Sc.C. 

There is a close similarity between public health work in cities and 
that in rural districts. The same diseases prevail in both sections, and 
the same human nature exists. It is a mistake to assume that a rural 
district is now more healthful than a city. The conditions which affect 
the health and vigor of a people may be divided into the environ- 
mental, or those outside of the body, and the personal, or those within 
the body. When people were ignorant of the causes of sickness, and 
were generally careless of public cleanliness, environmental conditions 
were unsanitary and unhealthful in proportion to the congestion of 
population. The death-rates of large cities before the days of efficient 
public health administration were about double those in the country. 
Public health work originated in cities. At first it was mainly environ- 
mental, and consisted in such measures as cleanliness of streets and 
yards, the disposal of sewage and garbage, and the installation of pure 
water supplies. These measures reduced the city rates for sickness 
and death to a marked degree, principally by preventing epidemics 
of those diseases which are associated with filth and water, such as 
typhus fever and cholera. A far greater reduction in the rates took 
place when the scope of public health work was extended to include the 
individuals themselves and the prevention of the spread of diseases 
by contact of one person with another. The result of the combined 
environmental and personal phases of public health work has been 
that the death-rates in large cities, had dropped to the rate that prevails 
in rural districts. The death-rate in New York City in 1900 was 
20.6 and hi the rest of the State it was 15.5. The New York City 
rate in 1910 was 15.9 and in the rest of the State it was 15.8; and 
since that time the city rate has usually been below the rural. A 
great problem in public health work is to reduce the rates for death and 
sickness in rural districts to a degree corresponding to their reduction 
in cities. It will come by adapting the efficient city methods to rural 
conditions. 

The environmental conditions in the country are not so favorable 
as they may seem. The outdoor air is fresh and pure, but country 
people spend half of their time indoors where the air may be as hot 
and close as hi a city tenement. The sun shines on the fields, but it is 
often excluded from shaded kitchens and bed rooms. The farm well 
from which generations have drunk, frequently becomes polluted with 
household drainage. The rural meeting places are often crowded and 



556 RURAL PUBLIC HEALTH WORK 

unventilated to a degree that would not be tolerated in New York 
City. Sewage disposal often consists in the surface exposure of excre- 
tions with no protection from flies, vermin, and domestic animals. 
The environmental conditions in a modern city are often more favor- 
able than they are in the country. The tenement house laws require 
a certain amount of window space for light and ventilation. The city 
government prevents overcrowding, requires the ventilation of public 
meeting places, removes the sew T age and garbage, and provides a pure 
water supply. There is need that many of the environmental condi- 
tions in the average rural community shall be raised to the standards 
which are enforced in cities. 

The frequent opportunities for contact of persons with one another 
increases the likelihood of the transmission of communicable diseases 
in the city, but it also promotes their control and suppression. The 
scattered population of rural sections facilitates the concealment of 
cases. Physicians are called only to grave cases, and there is usually 
an absence of inspections in homes and schools. Since there is seldom 
public provision for the care of cases, there is little incentive for them 
to be reported by the heads of families. The city is in contrast with 
the country in its personal public health work. Publicity of cases is 
readily obtained in the city, and their concealment is difficult. The 
concentration of population makes inspections and visitations easy. 
Clinics and hospitals provide for their isolation and care, and public 
health nurses search out the afflicted persons and persuade them to 
accept treatments. Babies and children in the poorer sections are 
supervised, and facilities are provided for them to obtain healthful 
food. The country will exceed the city in healthfulness only when there 
is a development of both the personal and the environmental branches 
of public health work. 

The standards of efficiency of a rural health department are those 
of a large city, but the machinery and methods of a city department 
require considerable modification before they can be applied to a 
country district. A city health department is highly organized with 
a commissioner at its head. All phases of its work are handled in a 
central office, and are administered by specialists and experts who are 
in frequent communication with the commissioner, and who require 
daily reports from the subordinates. Practically all health w T ork in a 
rural community is done by a part-time health officer. Rural health 
departments are deficient in experts in communicable diseases, in 
laboratory facilities, and in an engineering staff. These defects may 
be remedied by the cooperation and supervision of a State department 
of health, as they are in New York State. The New York plan is that 
the local department shall exercise primary jurisdiction over its own 
health affairs, and shall do the detailed work of discovering unsanitary 
conditions and cases of communicable diseases, and applying the 
ordinary remedies. The State supplies experts in epidemiology and 
engineering, and provides laboratory facilities at the call of the health 
officer. The system fails when the health officer acts only on complaints 



ORGANIZATION OF A RURAL HEALTH DEPARTMENT 557 

and does only what he is compelled to do. It is ideal and satisfactory 
when the health officer is active in recognizing local needs, and is prompt 
in reporting impending dangers before they become public scandals. 

ORGANIZATION OF A RURAL HEALTH DEPARTMENT. 

A rural department of health consists of four groups of persons: 

1. The health officer with his assistants, if he has any. 

2. The board of health. 

3. The practising physicians of the community. 

4. Lay organizations which are interested in public health work. 
The health officer is the executive officer of the local department of 

health, and is almost the only official with whom the public comes in 
contact. 

The board of health is the local official body or person to whom the 
health officer reports, and from whom he receives the authorization 
for his activities. It controls the law-making, legal and financial 
branches of local health work. 

The practising physicians compose the first line of defense against 
communicable diseases, and are officials of the department in that 
they are required to inform the health officer of every case of com- 
municable disease which they see. 

Lay organizations, such as village improvement societies, civic 
clubs, and neighborhood associations, form an essential part of the 
organization for carrying on local health work. They stimulate and 
encourage the local officials, and give them moral and financial support. 

Sources of Power. — The sources of power of a rural department of 
health are two in number : 

1. Statute laws; and 

2. The general desirability of public health work. 

The statute laws conferring authority on local departments are usually 
general in character; and officials may refuse to take a desirable action on 
the ground that it is not directly authorized by the statute law. But the 
broader and more usual interpretation of law is that a desirable course 
of action may be taken if it is not specifically forbidden by a law. 
Rural health officials are accustomed to base their actions on the ground 
of necessity or desirability to such an extent that they often forget 
the legal aspects of their work and try to exercise force for which there 
is no authority. The actual power of every health official is limited 
by the statute law as interpreted by the local court; but his authority 
to persuade and instruct is unlimited and unrestricted. It is an encour- 
aging sign of the times that people generally respond to notices by 
health officials and that recourse to the police and the courts is seldom 
necessary. 

The Rural Health Officer. — The health officer is the director of all 
the official public health work within his jurisdiction. The success of 
local public health work depends upon his knowledge, personality, 
and character. He is expected to maintain a continuous sanitary 



558 RURAL PUBLIC HEALTH WORK 

supervision over his territory, and to secure the remedies for the defects 
which he finds. All complaints affecting public health are referred to 
him for investigation and action. If a citizen is dissatisfied with his 
action, the appeal is to the board of health, or to the State department 
of health. 

The qualifications of a health officer are both personal and profes- 
sional. A health officer must have a pleasant manner, and exercise 
calm judgment, for the basis of his success is his powers of persuasion 
and instruction, rather than legal authority. Three types of physicians 
are undesirable as health officers: (1) the medical politician who seeks 
the office for money and follows public sentiment instead of leads it; 
(2) the independent doctor who learned his medicine years ago and 
who values no one's experience except his own; and (3) the city physi- 
cian w T ho attempts to apply the laws and methods of procedure of the 
city to a rural district in which they are not binding. A desirable type 
of health officer is a general practitioner of medicine who is up to date 
in his medical knowledge, is public spirited by nature and training, 
and is respected by his brother physicians and by the general public. 
An increasing number of men of this type are accepting the position 
as the scope and duties of the office become clarified and defined, and 
the legal and police duties are performed by boards of health and other 
officials to wdiom they properly belong. 

Health officer work is a specialty in medicine, and few physicians 
are qualified to perform it unless they have had special study and 
experience. The requirement of New York State is that a health officer 
must either have taken a special course in public health, or have given 
satisfactory evidence of special qualifications for the position. The 
special subjects in which a health officer must obtain proficiency are 
as follows: 

1. Public health laws and procedures. 

2. Communicable diseases, their present diagnosis, treatment, and 
prevention. The standard of knowledge of five years ago is now behind 
the times. 

3. Laboratory methods and procedures, especially methods of taking 
specimens and the interpretation of the reports. 

4. Water analyses and purification, and the supervision of water 
sheds and sources of supplies. 

5. The disposal of sewage and household wastes. 

6. Milk inspections. 

7. Infant welfare, child hygiene, and inspection of school children. 

8. Public health nursing. 

9. Methods of publicity and education. 

Courses of instruction in all these topics are offered by the University 
and Bellevue Hospital Medical College in New York City; the Albany 
Medical School; Syracuse University; University of Buffalo; Harvard 
Medical School, and the Johns Hopkins University. 

Activities. — The office of rural health officer is one of increasing 
importance and legal responsibility. While he is supposed to be strictly 



ORGANIZATION OF A RURAL HEALTH DEPARTMENT 559 

a health department official, yet duties under other departments are 
sometimes imposed upon him, probably because he is the most available 
official to do them. Over two hundred specific duties are imposed 
upon the health officer by the laws of New York State. Twenty-five 
distinct Juties are imposed by the insanity law, the labor law, the agri- 
cultural law, the educational law, and the penal code. Failure to per- 
form any one of the duties prescribed by law may subject the health 
officer to chrages of inefficiency. A health officer must constantly study 
the laws and sanitary code in order to perform his duties legally and 
efficiently. 

The public health activities of a rural health officer may be divided 
into field work and office duties. Field work is along the following lines : 

1. Communicable diseases, their control and prevention. 

2. Laboratory. 

3. Water supplies. 

4. Inspection of dairies and their products. 

5. Sewage and household wastes. 

6. Nuisances. 

7. Food sanitation. 

8. Sanitation of public buildings. 

9. Supervision of public health nurses. 

10. Infant welfare, child hygiene, and the medical inspection of 
school children. 

11. Education. 

Office work is conducted along the following lines: 

1. Records. 

2. Reports. 

3. Correspondence. 

4. Vital statistics. 

5. Study of public health subjects. 

Communicable disease work includes the following activities: 

1. Visitation of reported cases. 

2. Searching for unreported cases and investigations into the sources 
of infection. 

3. Instituting and maintaining isolations and quarantines. 

4. Taking cultures for diagnosis and release. 

5. Assisting family physicians in making diagnosis. 

6. Doing intubations, intravenous injections, spinal punctures, and 
other procedures requiring special skill. 

7. Assisting patients to receive medical and hospital treatment. 
Laboratory work includes the following activities: 

1. Maintaining a supply of diagnostic outfits, and of vaccines and 
serums from the State department of health. 

2. Distributing laboratory supplies to physicians. 

3. Taking cultures and specimens and administering vaccines and 
serums. 

4. Receiving and interpreting laboratory reports for physicians and 
patients, 



560 RURAL PUBLIC HEALTH WORK 

A health officer may be required to perform the following duties in 
relation to water supplies: 

1. The sanitary inspection of water sheds and sources of supply. 

2. Taking samples for laboratory examination. 

3. Giving advice regarding the location and construction of a public 
water supply. 

4. Investigating water supplies during an epidemic which may be 
water borne. 

5. Advising private persons regarding their water supplies. 
G. Condemning unsafe water supplies. 

Dairy inspections include the following duties : 

1. Visitation and inspection of dairies, and observation of their 
operation. 

2. Taking samples of milk for laboratory examination. 

3. Issuing permits to milk dealers. 

4. Giving advice to dairymen and dealers regarding the sanitation 
of their plants and methods of handling their products. 

5. Assisting in securing safe milk supplies for infants and children. 

6. Assisting in obtaining tuberculin tests for cattle. 

The disposal of sewage and household wastes may require a health 
officer to perform the following duties: 

1. Investigation of complaints regarding improper methods of dis- 
posal. 

2. Giving advice regarding disposal methods to private parties and 
to municipalities. 

3. Securing public dumping grounds and facilities for garbage 
disposal. 

4. Giving advice regarding the location, construction, and operation 
of disposal plants. 

5. Promoting the formation of sewer districts. 

6. The disposal of sewage and garbage during epidemics. 

7. The protection of streams and lakes against sewage. 

8. The protection of bathing places. 

The term nuisances includes almost every unsanitary or amoying 
condition which may affect health, and which is not classed under any 
other heading. A health officer's activities include the following duties: 

1 . An investigation of every complaint, and a determination whether 
or not it affects health. 

2. An attempt to secure its abatement by the party maintaining it. 
A health officer has the following duties to perform in relation to 

food sanitation: 

1. Investigating all cases of alleged food poisoning, and taking 
samples of the food for a bacteriological examination. 

2. Inspection of places for the sale of foods and drinks, and issuing 
certificates of inspection to those found sanitary. 

3. Advice to the managers regarding the proper methods of handling 
foods and drinks in restaurants and other places in which foods and 
drinks are consumed. 






ORGANIZATION OF A RURAL HEALTH DEPARTMENT 561 

The principal buildings which a health officer inspects are school 
houses, theaters, and public halls. He is to observe especially the 
following points : 

1. Cleanliness. 

2. State of repair of the building and rooms. 

3. The plumbing and disposal of sewage. 

4. The water supply. 

5. Overcrowding. 

6. Ventilation. 

A health officer performs the following duties in infant welfare and 
child hygiene: 

1. The medical inspection of school children. 

2. Advice to teachers and parents regarding the correction of the 
defects which are found. 

3. Establishing milk stations and infant welfare centers. 

4. The examination of poorly nourished and defective infants. 

5. Cooperation with public health nurses and social organizations 
in promoting the health of children and infants and their mothers. 

Educational work includes the following activities: 

1. The distribution of circulars of information to those caring for 
cases of communicable diseases. 

2. Giving advice to parents and others who are caring for cases of 
communicable diseases. 

3. Giving information to physicians, nurses, and social workers 
regarding all phases of public health work in his jurisdiction. 

4. Lecturing on public health topics. 

5. Giving interviews to reporters and preparing instructive articles 
for the newspapers. 

6. Conducting public health exhibits. 

7. Conferences with other officials. 

No health officer can do efficient field work unless he is prompt and 
proficient in his office work. He needs to keep full records in order to 
produce the detailed information with which to confirm and justify 
the judgments which he makes and the advice which he gives. He 
must make public reports in order to convince officials and the public 
of the efficiency, value, and necessity for public health work in his 
locality. His influence and reputation will depend largely upon the 
promptness with which he answers letters and conducts his corre- 
spondence. He is expected to be familiar with the records of communi- 
cable diseases in his jurisdiction, and with the death-rates and the causes 
of death in his locality. 

The time which a health officer spends in the study of public health 
topics may rightly be counted as devoted to the discharge of his official 
duties. The study may be along the following lines: 

1. Reading books and periodicals on public health topics. 

2. Preparing addresses. 

3. Attending educational meetings and clinics. 

4. Planning future work. 
36 



562 RURAL PUBLIC HEALTH WORK 

This brief enumeration of the duties of a rural health officer indicates 
the scope and importance of his work and the necessity of his having 
special preparation for the discharge of his duties. He need not be a 
specialist in any line, but he is expected to recognize a serious condition 
when it develops, and to be willing and able to procure expert advice 
and assistance when the condition is beyond his knowledge and experi- 
ence. 

Some of the duties which a rural health officer perforins are com- 
pulsory, and others are largely optional. The minimum duties which 
are required are the isolation of reported cases of communicable disease, 
the investigation of complaints, and the suppression of gross unsanitary 
conditions and nuisances which are evident to citizens. These duties 
are chiefly clerical and police, and may be performed by an intelligent 
layman almost as well as by a trained health officer. A health officer 
who performs only these duties and acts only on reports and complaints 
is inefficient and practically useless. The efficient health officer searches 
for carriers and mild cases of disease, promotes child welfare, and does 
active educational work. He is a leader and does his work because he 
wishes to protect and promote the health of the community regardless 
of what he makes out of the office. 

Procedure by the Health Officer. — In some of the activities of a 
health officer, the persons with whom he deals are subject to legal 
requirements, and in others their compliance with his advice is volun- 
tary. When his activities affect a person who is subject to the pro- 
visions of the public health law or the sanitary code, or to the orders 
of a board of health, a health officer must follow a certain procedure 
in order to make his actions legal. He must be particularly careful 
of the legal aspects of his actions in the isolation and control of cases 
of communicable disease, in granting or refusing permits, and in sup- 
pressing nuisances. The steps which he must take are: (1) investiga- 
tion; (2) information, and (3) notification. 

The first step which a health officer takes is to obtain sufficient 
evidence to justify his actions if the case should come to court. He 
will usually obtain the evidence by means of an investigation made by 
himself or his legal representative. He may also act on the evidence of 
other persons, but if he does so, his informers might possibly change 
their statements when they are questioned publicly. If he makes an 
investigation, his written report will be accepted in court as presump- 
tive evidence of the facts which he states. If a health officer acts 
without making an investigation or obtaining sufficient evidence, he 
may be held liable for illegal actions. 

The second step is to give to the person who is subject to his control, 
full information regarding the condition which he finds. If a person 
does not understand the nature of an unsanitary condition, his ignor- 
ance may be taken as an excuse for failure to remedy it. 

The third step is to notify the responsible person what he must do 
to remedy the objectionable condition. He will discuss the matter 
with the person, and if possible, will come to an understanding with 



ORGANIZATION OF A RURAL HEALTH DEPARTMENT 563 

him regarding the manner and time of carrying out the suggestions and 
requirements. The notification will usually be verbal, and if a health 
officer is patient and tactful, mention of legal means or force will 
seldom have to be made. But if he finds that his suggestions are likely 
to be ignored, it is his duty to serve them in writing, and to include the 
statement that failure to comply with them will be followed by legal 
action against the offender. 

A notification by a health officer is popularly called an order; but 
there are two real distinctions between a notification and an order: 
(1) the power to issue a legal order lies with the board of health or the 
State department of health; and (2) a person who disregards a notice 
given by a health officer, cannot be punished for the act of disobedience ; 
the penalty is for continuing to maintain the condition which menaces 
health. On the other hand, the act of disobeying or ignoring an order 
of a board of health is itself a misdemeanor which is punishable. Much 
of the unpleasantness, unpopularity, and ill-feeling associated with the 
office of health officer has arisen from the health officer's assumption 
of the power to give orders on his own initiative. His duty is to inform 
offenders of the nature of their acts, to instruct them regarding the 
proper remedy, and to point out to them the consequences of their 
neglect to comply with his directions. He is neither a police officer 
nor a prosecuting attorney. If a person fails to heed his directions, 
the next step which the health officer is to take is to report the matter 
to the board of health for its action. It is not the duty of the health 
officer to use force or legal means to enforce compliance with his instruc- 
tions, unless he is specifically authorized to do so by his board of health. 
An exception is that public sentiment and the courts will uphold a 
health officer in placing a police guard to maintain the isolation or quar- 
antine of a case of contagious disease, for this is an emergency in which 
there is no time for deliberation. Rural boards of health meet infre- 
quently, but a health officer can consult an individual member readily, 
and can secure an unofficial authorization to take the necessary steps 
to abate a condition that is a grave menace to health. If he does this, 
he may feel assured that the board of health will sustain him at its 
next meeting. The principle involved is that it is not in accord with 
American ideas of government that any one man alone shall be inves- 
tigator, judge, and prosecuting officer. Active health officers have 
often assumed power to give orders because boards of health fail in 
their duty to consider matters that are brought before them, and to 
assume their share of responsibility. The cooperation of a board of 
health with the health officer is necessary in dealing with those persons 
who defy the health officer. But a health officer has recourse to legal 
action so seldom that he often forgets the proper method of procedure 
when force or legal action is necessary. 

A health officer is not free from responsibility when he has made a 
report to the board of health regarding a condition which he is unable 
to correct. He is still the executive officer in charge of the situation, 



504 RURAL PUBLIC HEALTH WORK 

and must direct the performance of the action which the board author- 
izes. This action may be either summary or legal. 

Summary action means that the board instructs the health officer 
to remedy a condition at public expense. For example, it may authorize 
him to compel the observance of quarantine, to employ persons to 
cart away a mass of garbage, or to clean an unsanitary cesspool. When 
summary action is taken, the cost may be recovered from the person 
who is responsible for the condition. 

When the board authorizes a legal action against an offender, the 
health officer must make affidavits on which the case is founded, 
obtain evidence, and advise the lawyer who is in charge of the case. 
He must keep in touch with every phase of the action, and follow up 
the case to see that the conditions are finally remedied. 

Board of Health. — A health officer reports to some official body 
and is subject to its orders. This governmental body may be a board 
of health whose members are appointed especially for the purpose, 
or health matters may come before a board which performs a variety 
of other duties. 

The duties of a board of health may be discussed under five headings : 
(1) the appointment of a health officer; (2) financial; (3) general policies; 
(4) legal activities; (5) direct assistance to the health officer. 

Appointing a health officer is probably the most important act of a 
board of health. There are often few physicians or perhaps only one 
available for the office in a rural section. The law presumes that the 
board will be able to choose a competent person to fill the position. 
If no available person is qualified, it is still the duty of the board to 
appoint an acting health officer until one can qualify. 

A board of health has three financial duties to perform : (1) to prepare 
a budget; (2) to direct the expenditure of the funds; (3) to audit the 
bills which a health officer incurs. 

The items of expenses of a rural health board are usually as follows : 

1. Pay of the health officer and his expenses. 

2. Pay of nurses and inspectors. 

3. Fees of the registrar of vital statistics, and of physicians for mak- 
ing reports. 

4r. Office rent. 

5. Stationery and office supplies. 

6. Postage, telephone calls, and messenger service. 

7. Maintaining quarantines, and doing disinfecting work in cases of 
contagious disease. 

8. Expressage on laboratory supplies. 

9. Suppression of nuisances. 

10. ^Extraordinary expenses during the suppression of epidemics. 

11. Educational work, lectures, and exhibits. 

The standards of expenditure by rural boards of health vary widely. 
The law of New York State established the minimum salary of a health 
officer upon the basis of ten cents for each inhabitant in his jurisdiction. 
His salary usually amounts to more than all the other expenses com- 



ORGANIZATION OF A RURAL HEALTH DEPARTMENT 565 

hined, and few rural distriets spend annually more than twenty-five 
cents per capita on public health work. This is less than half the rate 
of expenditure in the larger and more progressive cities. 

The general lines of public health work in a community are largely 
determined by the board of health, partly by its financial appropriations 
and partly by its support of the health officer in his activities which do 
not require the expenditure of money. If it is generally known that a 
board of health is active in its support of the health officer, people will 
give heed to his suggestions. 

The source of authority for the acts of a board of health is the 
statute law. Some laws require a board to perform specific duties; 
others permit a board to do certain things; still other laws are general 
and their broad interpretation allows a board to do almost anything 
reasonable to promote public health. For example the law of New 
York State prescribes that a board of health must control persons 
afflicted with contagious diseases; it permits boards to engage in anti- 
mosquito work; and a few boards conduct exhibits and lectures under 
a broad interpretation of the section giving them authority to direct the 
health officers in the performance of their duties. A board of health is 
usually willing to perform the duties required by law ; but they are not 
always willing to engage in new or unusual lines of work except in 
response to public sentiment. The usual methods of obtaining action 
by a board of health is to conduct a campaign of education in order to 
arouse a public demand for the activity. A health officer may conduct 
any line of work which is merely advisory and educational and in which 
the people's compliance to his suggestions is voluntary; but he cannot 
compel obedience to his suggestions unless the board specifically 
authorizes this action. 

A rural board of health has authority to conduct legal work along 
three lines: (1) the adoption of a local sanitary code; (2) issuing 
special orders; (3) authorizing and conducting prosecutions against 
offenders. 

The statute laws are usually general in their nature and application. 
Local boards of health have authority to enact a sanitary code whose 
regulations deal with the details of the application of the statute law. 
For example the public health law of New York State requires a local 
board to guard against the introduction of infectious diseases; but a 
local board may prescribe the manner of establishing a quarantine, 
the length of time of an isolation period, and the method of disinfecting 
the sick rooms. A local sanitary code usually deals with subjects with 
which a health officer has to deal frequently. The following are among 
the subjects which local health ordinances usually cover : 

Communicable diseases. 

Dairy regulations. 

Food sanitation. 

Disposal of household wastes. 

Cesspool construction and cleaning. 

Privy construction and management. 



566 RURAL PUBLIC HEALTH WORK 

Disposal of stable manure. 

Suppression of flies and mosquitoes. 
Pig pens and chicken yards. 
Slaughter houses. 
Smoke. 

I 'nnecessary noises. 
Spitting. 
A sanitary code greatly simplifies the work of a health officer. The 
fact that a condition is a violation of the sanitary code is sufficient to 
condemn it and to subject the violator to a penalty. A sanitary code 
has the effect of an order to the health officer that certain conditions 
are to be considered detrimental to health and to be subject to his 
control. If an unsanitary condition or nuisance develops which is not 
covered by the sanitary code, a health officer must prove not only that 
it exists but also that it is detrimental to health. It is the duty of 
every board of health to enact a sanitary code. 

The power of a local board of health to enact a sanitary code is 
unquestioned in the courts. The principle of home rule and control 
prevails in health matters as in other branches of governmental activi- 
ties, provided that no regulation conflicts with a statute law or other 
provision made by a higher authority. 

When an unsanitary condition is not covered by a specific provision 
of the law or sanitary code, a board of health may investigate it and 
issue a special order for its correction. This order is a special regula- 
tion made for that case only. It has the effect of the sanitary code, 
with the additional force that it deals with a definite condition that is 
already developed, and that it is directed to one person. It has the 
same legal standing as a court order. 

The full legal proceedings in issuing an order are as follows: 

1. The matter shall be considered at a meeting of the board of health. 
If the members have personal knowledge of the condition, they may 
make their decision without an investigation or hearing. The board 
may conduct a formal hearing, and for that purpose it has the power 
of a local court in summoning witnesses and taking testimony. 

2. The decision and order shall be entered in the minutes of the 
board. 

3. The order shall be served upon the offender, and a copy of it, 
together with an affidavit of service by the serving officer, shall be filed 
with the board. 

If an order is disregarded or disobeyed the next step is to begin legal 
proceedings against the offender. The proceedings may be an arrest 
upon criminal charges of disobedience, or a civil action for the collection 
of a penalty for maintaining a condition that is detrimental to health. 

One of the duties of a board of health is to authorize and conduct 
prosecutions for violations of the sanitary code or for maintaining 
unsanitary conditions after the health officer has been unsuccessful 
in his efforts to remedy the condition. The proper agent of the board 
is not the health officer but a lawyer employed for the purpose. A court 



ORGANIZATION OF A RURAL HEALTH DEPARTMENT 567 

action is a last resort and is seldom instituted in rural districts, for it is 
usually difficult to obtain a conviction when all the parties at court 
know one another intimately. Effective results can nearly always be 
obtained by making publicity of investigations and calling the atten- 
tion of offenders to their liability to a fine or penalty. 

A board of health may often be of great direct assistance to a health 
officer if each member will be ready to visit persistent offenders with 
the health officer. Many persons refuse to obey a health officer because 
they believe him to be vindictive and malicious. A member of the 
board can act as a peacemaker and instructor, and his presence will 
often settle a matter which no health officer alone could handle. The 
fact that the board of health is supporting the health officer is usually 
sufficient to bring offenders to terms. 

The Physician and the Health Department. — Medical service is 
usually considered to be a private matter, to be chosen and bought 
like clothes, and accepted or rejected according to the personal desires 
of the individual. The practice of medicine is conducted along two 
general lines, (1) curative and (2) preventive. Family physicians 
practice curative medicine and do little preventive work. They are 
dependent for their living upon those who hire them. They are the 
servants of their patients and must render the service for which they 
are paid. People call a physician to cure them of a sickness that has 
already developed, but they are seldom willing to pay a physician to 
advise them how to keep well and vigorous and to avoid conditions 
which may be dangerous to health. 

Preventive medicine is conducted along two lines: (1) personal and 
(2) social. Personal preventive work consists largely in performing 
such duties as taking precautions for the protection of other persons, 
reforming unhygienic personal habits, and accepting vaccines against 
diseases which are not existing in a given locality. These activities 
are unpopular, and a private practitioner cannot be expected to make 
them a prominent part of his work. The majority of people have no 
control over many unhealthful conditions amid which they live and 
work, and it would be futile for them to employ private physicians for 
advice along these lines. Over half of the activities of a practitioner of 
preventive medicine are conducted along such lines as public water 
supplies, milk inspections, public sewage disposal, housing, recreation, 
and conditions in industrial establishments. The control of these 
matters is not within the scope of the duties of a private practitioner of 
medicine, but it belongs to specialists in departments of health . Private 
practitioners of medicine are inexperienced and untrained along most 
preventive lines of work, and will remain so until the people become 
educated to demand that their medical advisors shall be responsible 
for preventive work. But general practitioners of medicine are not 
entirely free from responsibility in preventive medicine, for they have 
definite duties to perform under the public health laws, particularly 
those relating to communicable diseases and vital statistics. 

Reporting cases of communicable diseases is universally recognized 



568 RURAL PUBLIC HEALTH WORK 

as the duty of a physician. The New York State Public Health Law, 
Section 25, requires a physician to make a report to the health officer 
concerning every case of certain communicable diseases which he 
attends. The New York State Sanitary Code, Chapter 2, Regulation 
2, requires the report to be made within twenty-four hours after the 
case is first seen, and immediately if it is on a dairy farm. The effect 
of these legal requirements is to make the physicians of a community 
an integral part of a department of health. Every physician is an 
official diagnostician for his local department, and the legal standing of 
his report is the same as that of a report made by a health officer. The 
report is the ground which justifies a health officer in taking official 
action for preventing the spread of the disease. A report made by a 
physician is not a violation of his confidential relations to his patients. 

The diseases which a physician must report are specified by the State 
department of health. Practically all departments of health require 
the reporting of such well-known diseases as smallpox, typhoid fever, 
and scarlet fever. There are twenty-eight diseases on the list in New 
York State. 

Cases of communicable diseases may be divided into three classes: 
(1) those which are plainly evident; (2) those which are mild or have 
only suspicious signs; (3) carriers. The evident cases present no diffi- 
culties to a family physician, but he is often in doubt in regard to sus- 
picious cases and carriers. It is the intention of the law that a physi- 
cian shall make a diagnosis promptly in every case to which he is called, 
and that he shall use every available means of making a diagnosis. 
The New York State Sanitary Code, Chapter 2, Regulation 10, requires 
a physician to take cultures from the throats of persons in whom there 
is reason to suspect the existence of diphtheria. The attitude of physi- 
cians toward reporting suspicious cases and carriers depends to a great 
extent upon the health officer. The larger cities meet this difficulty 
by employing disinterested experts as official diagnosticians. A rural 
health officer is usually the only health official that is immediately 
available. If he is an ignorant bluffer, he may get the family physician 
into personal difficulties with the patient. If he belongs to the rubber- 
stamp variety, he will simply agree with the doctor, and the result will 
be that the responsibility is placed entirely upon the family physician. 
The exact scope of duty of the health officer is not defined, but it is 
reasonable that he should be held responsible for the diagnosis of a 
suspicious case which is reported to him by a physician. There is 
seldom any difficulty between a physician and a health officer when the 
health officer is competent and is willing to assume his proper share of 
responsibility. 

The state departments of health of many of the states assist family 
physicians in making diagnoses by examining specimens and cultures 
sent to the laboratories by physicians. The Department of Health of 
New York State provides the mailing outfits for the specimens. It 
also sends expert diagnosticians at the request of local health officers. 

The question often arises in rural communities whether or not the 



ORGANIZATION OF A RURAL HEALTH DEPARTMENT 569 

health officer shall examine every case that is reported to him. It 
would he ideal if he should personally see every case, but a family 
physician has good grounds for objecting to the visits of a health officer 
who is dishonest, or ignorant, or untactful. 

An active health officer who is a competent diagnostician will be 
disquieting to a rural physician who has been accustomed to independ- 
ence in action and expression, who ceased to study years ago, and who 
diagnoses respiratory diseases as colds, typhoid fever as indigestion, 
and meningitis as nervousness. But departments of health are raising 
the standards of the practice of health. They constitute almost the 
only power that compels physicians to study and to keep up with the 
times. 

Physicians are expected to protect the public against the spread of 
communicable diseases. The duty is legally recognized in the Sanitary 
Code of New York State, Chapter 2, Regulations 11, 16, and 17, which 
require a physician to take measures for the isolation of his patients 
who have communicable diseases, and for the proper disposal or dis- 
infection of their excretions. Many physicians shirk this responsibility 
on the ground that it is not their duty to place restrictions on their 
patients for the benefit of other persons. Other physicians object to 
the visits of a health officer and then fail to carry out the isolation and 
disinfection. A great deal of the difficulty and unpleasantness con- 
nected with isolations and disinfections may be avoided by the use of 
official circulars of information, such as are issued by the New York 
State Department of Health, giving a uniform method of procedure for 
each disease. If one of these circulars is left with each case of com- 
municable disease, both the physician and the health officer and the 
head of the afflicted family can readily come to an agreement regarding 
the management of the case. 

The removal of restrictions upon a family is not the privilege of a 
physician. Instituting an isolation or quarantine is a legal action and 
the health officer is the only person to terminate the period legally. It 
frequently lasts for a period much longer than that of the visits of the 
physician. A health officer wili usually accept the family physician's 
statement that the patient may be released, but in case of doubt he 
may properly require the physician to give a written statement that 
the patient cannot give the disease to another. This statement is 
equivalent to saying that a patient is not a carrier, and a physician will 
seldom give it unless he has complied fully with all legal and scientific 
requirements. 

The departments of health of many states provide antitoxins, 
serums, and vaccines for the prevention or treatment of many diseases. 
Physicians sometimes refuse to make use of them on the ground that 
they do not believe in them. Such statements are confessions of igno- 
rance.' The preparations represent standard and approved methods of 
dealing with the diseases with which they are associated. If a physi- 
cian fails to make use of them in a case in which recovery is unsatis- 
factory, there is a strong presumption that he is guilty of neglect. 



570 RURAL PUBLIC HEALTH WORK 

Physicians have a public duty to perform in instructing their tuber- 
culosis patients in the measures for preventing the spread of the disease. 
The laws of New York State require every physician to exercise efficient 
supervision over his tuberculosis cases, but the laws also provide that 
he may be relieved of that responsibility if in reporting a case he is 
unable or unwilling to assume the duty. The supervision then devolves 
upon the health officer or upon the public health nurse if there is one. 

Physicians are required to issue certificates of death and to report 
the births which they attend. These duties are often irksome, par- 
ticularly when the physician must make a considerable effort to ascer- 
tain such details as ages, occupations, and the names of parents. But the 
importance of the records justifies the law T that each physician shall 
report his cases in all the required details. 

Physicians sometimes feel that departments of health are encroach- 
ing upon their prerogatives and practice in making provision for expert 
consultations and for free treatments. This criticism in New York 
is made particularly in regard to tuberculosis, venereal diseases, and 
poliomyelitis. The State Department of Health has assumed a certain 
amount of supervision over these cases because physicians generally 
avoid them. A canvass of rural section in campaigns for establishing 
tuberculosis hospitals shows that over half of the advanced cases of 
tuberculosis have no physician regularly in attendance, and the exami- 
nation of men drafted for the national army show 7 that not 10 per cent, 
of the incipient cases have been told by any physician that they have 
the disease. A canvass of physicians in one large section of New York 
shows that a large proportion of the leading physicians refuse to treat 
venereal diseases. When the number of cases of venereal diseases in 
drafted men entering the army cantonments is compared w T ith the 
number under treatment by physicians, it is found that very few are 
receiving treatment except possibly for a few days during the acute 
stage. The experience in the State clinics for the care of paralytic 
and weakened conditions following poliomyelitis demonstrates that 
most physicians consider the cases to be a burden and are anxious for 
the State to assume their oversight and care. Since physicians have 
generally neglected these diseases, the people are not accustomed to 
consult their medical advisors regarding them. The State department 
of health is educating people in the need of seeking medical advice for 
these conditions and of taking it until they are not only able to go to 
work but are also free from disease germs and physical evidences of 
disease. It would be to the personal advantage of physicians if they 
would cooperate in this educational work, would become proficient in 
the diagnosis and treatment of the conditions and would seek to treat 
the cases instead of to avoid them. It is not the policy of a department 
of health to make provision for giving advice and treatments which 
individuals can secure for themselves. The policy of the departments 
is to place their facilities at the disposal of all physicians who are willing 
and desirous to retain control of their patients and to encourage people 
to seek advice from their own private doctors. 



ORGANIZATION OF A RURAL HEALTH DEPARTMENT o71 

Hie duties which a department of health requires of a physician are 
no more than a conscientious physician would observe for the protection 
of his patients and the public. The services which an efficient depart- 
ment of health renders to a physician far outweigh the slight incon- 
venience which it imposes upon him in complying with its requirements. 
A rural physician in New York State receives direct benefit from the 
following activities of the State health department. 

1. Providing culture tubes and other diagnostic outfits and mailing 
cases for sending them to the laboratory. 

2. Examining specimens and reporting the findings to the physician. 

3. Providing experts to diagnose obscure and unusual cases of con- 
tagious disease, and to obtain laboratory specimens and administer 
treatments by the more difficult procedures such as spinal punctures 
and drawing blood. 

4. Providing epidemiologists and public health nurses to investigate 
the causes of an outbreak of a communicable disease. 

5. Providing vaccines and serums for treating the sick and immuniz- 
ing the w T ell. 

6. Providing muscle trainers to supervise the care of crippled children, 
especially those suffering from poliomyelitis. 

7. Conducting clinics for assisting physicians in giving advice and 
treatment to cases of tuberculosis, venereal diseases, and poliomyelitis. 

8. Supplying instructive pamphlets to be given to cases of contagious 
diseases. 

9. Instructing physicians in diagnosis, treatment, and other sub- 
jects which are of direct value to them in their daily practice. 

10. Calling the attention of patients to conditions of which they 
were not aware and directing them to physicians for advice and 
treatment. 

Lay Societies. — Lay societies often take an active interest in public 
health and are recognized as unofficial parts of departments of health. 
The list of such societies includes boards of trade, granges, civic clubs, 
village improvement societies, mothers' clubs, and parent teachers 1 
associations. A health officer can usually find an organization that will 
support his work and promote its enlargement. The history of nearly 
every public health movement that is successful is that it is considered 
at first by only a few individuals, is then promoted and financed by 
an organization or society, and finally when its need and success is 
demonstrated, it is assumed by a board of health and conducted at 
public expense. An efficient health officer will work in harmony with 
the societies in his jurisdiction. He will instruct them in the needs of 
his district, advise them regarding plans of action, and assist them in 
campaigns of education. The efficiency of public health work in a 
rural community will depend largely upon the existence of a local 
organization composed of public-spirited citizens. 

The public health activities that are usually promoted by lay 
organizations are as follows: 

1. Public health nursing. 



572 RURAL PUBLIC HEALTH WORK 

2. Forming a sewage district. 

3. Conducting the collection of garbage. 

4. Promoting pure milk. 

5. Food sanitation. 

(>. Organizing clean-up campaigns. 
7. Anti-fly and anti-mosquito work. 

S. The examination of school children, and the correction of their 
defects. 

9. Infant welfare work and milk stations. 

10. The care of crippled children. 

11. Anti-tuberculosis work. 

Inspectors. — The assistants which a rural health officer will need 
as his work increases are an inspector and a public health nurse. The 
inspector will look after environmental conditions outside of homes, 
such as sewage disposal and nuisances, while the nurse will do personal 
work within the homes. 

The essential qualifications of an inspector are that he be an intelli- 
gent, sensible, honest man who is observant, is able to make a clear 
report upon what he sees, and is not given to talking and making threats. 
He need not be educated or trained in technical work. A type of person 
who makes a good inspector is the one who is in demand as a man of all 
work. He will usually be able to suggest a practical remedy for the 
insanitary conditions which he finds. His legal standing will be that 
of agent of the health officer. He will have a right of access to private 
property, and the legal standing of his reports will be that of the report 
of the health officer. 

The activities which an inspector will usually carry on are as follows : 

1. The construction and maintenance of fly-tight, sanitary privies. 

2. The disposal of dead animals, garbage, manure, and other sub- 
stances that are subject to decay. 

3. The prevention of the pollution of streams and lakes. 

4. Cesspools and sewage disposal. 

5. The elimination of the breeding places of flies and mosquitoes. 

6. The supervision of quarantined premises. 

7. Disinfections and renovations after the termination of cases of 
communicable diseases. 

8. Follow-up work after inspections made by the health officer. 

9. The inspection and suppression of nuisances. 



PUBLIC HEALTH NURSING. 

The original work of a health officer was to control epidemics and 
suppress nuisances, and he dealt with those conditions only when they 
were evidently dangerous or directly annoying. The work has now been 
extended to include the prevention of diseases, the correction of remedi- 
able defects and the promotion of hygienic habits of living. The newer 
public health work teaches parents to care for their babies, and to 






PUBLIC HEALTH NURSING 573 

bring up their children in correct habits of diet, play, work, and rest. 
It supervises the mode of life of adults who are subject to tuberculosis 
and other weakening diseases. It consists largely in the personal educa- 
tion of individuals, especially mothers. Parents and householders with 
financial means seek advice from their family physicians, but about 
one-quarter of all the people caimot afford to buy the services of a 
physician except for cases of disabling sickness. These people go 
unadvised and unled in health matters unless the department of 
health reaches them. The promotion of all phases of preventive medi- 
cine is one of the recognized duties of a rural health department. The 
health officer cannot spend the time to do this work, and if he could, he 
would not be fitted for it. This work belongs to a public health nurse. 
Every community of 3000 people will find abundant work for a full- 
time public health nurse. 

The public health nurse is the field agent of the health officer. 
She spends most of her time visiting in private homes. She recognizes 
defects and unhygienic habits, brings children and patients to physi- 
cians or clinics for examination, and makes the arrangements for their 
correction and treatment. Physicians are nearly always willing to give 
medical advice and surgical treatment provided some one assumes the 
burden of explaining the nature of the diseases and defects and makes 
the arrangements to carry out treatments effectively. The public 
health nurse may have to spend an hour or two persuading and 
instructing a parent to submit her child to an examination or operation 
which takes only a few minutes of a doctor's time. She makes it pos- 
sible for people in moderate financial circumstances to receive the 
benefit of medical and surgical advice which may prevent a severe 
attack of sickness or may enable a patient to return to a useful occupa- 
tion. She is a teacher of the newer phases of public health work and 
brings a knowledge of the possibilities of preventive and corrective 
work to those who would otherwise remain ignorant and would become 
weaklings because the means of help were not brought to their attention. 

Charitable organizations often support visiting muses to do bedside 
nursing for those who are actually sick. This work is not to be con- 
fused with that done by a public health nurse employed by a depart- 
ment of health. A visiting muse goes where she is called by physicians. 
She spends her time musing a few cases, and she can see only a few in a 
day. Her work usually ceases when the patient no longer requires the 
visits of the physician. In contrast with her work a public health muse 
does little bedside nursing herself. She may instruct a householder 
how to care for a patient or she may assist in securing a bedside nurse ; 
but her peculiar work is to instruct people how to prevent sickness and 
how to promote greater vigor and strength in those who are only slightly 
below standard in health. There is a field for both a visiting nurse and 
a public health nurse in a community, but the two activities caimot be 
combined in one person, for when they are, the care of a few bed cases 
monopolizes the entire time of the nurse. 



574 RURAL PUBLIC HEALTH WORK 

The activities of a rural public health nurse are usually conducted 
along the following lines: 

1 . Suppressing epidemics. 

2. Anti-tuberculosis work. 

3. Infant welfare. 

4. The inspection of school children. 

5. Child hygiene. 

G. General inspections. 

A nurse will render valuable assistance to a health officer in searching 
for cases of communicable disease to which no physicians are called. 
She will discover mild and missed cases of the more severe diseases, 
such as scarlet fever and diphtheria. If an epidemic of disease breaks 
out, she will make a house to house canvass, instructing parents in the 
signs of the disease, the methods of isolation, and the means of prevent- 
ing the spread of the disease. She is especially valuable in the control 
of the minor diseases, such as mumps, German measles, and chicken- 
pox. A great value of her work is that she educates parents in the need 
of isolating their children when they have a mild sickness of an undeter- 
mined nature. 

Anti-tuberculosis work is not effective unless there is a visiting nurse 
to supervise the cases. The nurse is especially valuable in instructing 
patients during the pretubercular stage of the disease. She can combat 
an unreasoning fear of consumption and can popularize a free discus- 
sion of the disease. She can demonstrate the curability of the disease 
and promote a knowledge of its true nature and of the usual history of 
a case. She can supervise the advanced cases, secure medical or sana- 
torium treatment for them, and instruct their families in precautionary 
measures. 

The greatest saving of life during the last twenty-five years has been 
among children under five years of age, and has been accomplished 
largely by means of public health nurses. The nurses visit and instruct 
mothers in their homes, conduct classes for mothers and older sisters, 
establish milk stations, and promote a sanitary milk supply. Infant 
welfare is one of the most important phases of the work of a public 
health nurse. 

A broad field of usefulness of a public health nurse is the discovery, 
prevention, and correction of defects which prevent the physical and 
mental development of children. These defects may be discovered by 
a medical inspection of school children. The formal examinations are 
made by the school physician, but securing the correction of the defects 
is the work of the public health nurse and will seldom be done unless a 
nurse is employed. The discovery and correction of defects and the 
control of the conditions which produce them are included in the general 
subject of child hygiene. These varied activities in a rural community 
will be conducted by a public health nurse. Examples of the conditions 
which she will investigate and treat are defective sight and vision, 
paralyses, poor nutrition, tuberculosis, adenoids and tonsils, and mental 
deficiency. 



PUBLIC HEALTH LABORATORY 575 

A public health nurse will make inspections of places for the sale of 
foods and drinks, and of schools, theaters and other meeting places. 
She will report the unsanitary conditions which she may observe on 
her rounds of duty. 

Public health nursing is universally recognized as necessary in large 
cities, but its need is not always felt in rural places. The usual method 
of starting the work is to arouse the interest of an organization or com- 
mittee that will raise the money to employ a nurse for a brief period 
with the expectation that if the work is successful, it will be continued 
as a governmental activity. Advantage may be taken of an epidemic 
to urge a board of health to employ a nurse to canvass the houses and 
schools for the discovery of cases. She will discover many defects 
among children and conditions that require attention, and her report 
may be used as a basis for urging the permanent employment of a 
public health nurse. 

The public schools afford an excellent field of work for a rural public 
health nurse and are especially valuable in starting the work. Defects 
begin to show their bad results when a child is compared with others 
in school and the nurse can use the observations and the reports of the 
teachers in approaching the parents at home and persuading them to 
allow the correction of their children's defects. The nurse will also be 
enabled to reach the younger children and the babies, and she will 
cover her whole field of service through the schools. 

Public health nursing in the country differs from the work in the 
large cities in that the rural nurse has no fixed schedule of duties and 
can seldom lay out her work for many days in advance; but she must 
hold herself ready for any phase of the work as it develops. An efficient 
nurse makes her own schedule and engagements and adapts herself 
to her district. Work in rural sections appeals to many public health 
nurses because of its varied nature, its freedom, and its independence 
from rigid discipline. A conscientious nurse will regard the freedom and 
liberty of action as a responsibility which is to be met with her best 
efforts. Rural public health nursing has been amply justified wherever 
it has been properly managed, and its extension will be the next great 
development in rural public health work. 



PUBLIC HEALTH LABORATORY. 

The practice of modern medicine is impossible without a laboratory. 
Physicians were formerly guided by clinical observation only. Physical 
examinations have been used scarcely a hundred years and bacteri- 
ology has developed within the memory of physicians who are still 
in active practice. Clinical observations, physical examinations, and 
laboratory analyses form a trinity of diagnostic methods, each of which 
is necessary and none of which is complete in itself. Every physician 
can employ the method of clinical observation and physical examina- 
tion, but only a few have special skill and experience for doing labora- 



576 RURAL PUBLIC HEALTH WORK 

ton work. Small communities cannot afford to maintain their own 
local laboratories. New York State provides the laboratories at the 
expense of either the counties or the State. It is one of the necessary 
activities of a State department of health to supply the laboratory 
needs of rural communities. It is equally the duty of physicians to 
make use of the laboratory for the benefit of their patients, the public, 
and themselves. The health officers of New York State are the agents 
of the laboratories of the State Department of Health, for they main- 
tain supplies of culture tubes, vaccines, serums, and other laboratory 
material, and give them to physicians on request. They also assist 
physicians in obtaining specimens and in giving vaccines and serums. 
The activities of a public health laboratory are usually confined to 
diseases which are communicable and conditions which have a direct 
bearing upon public health. The laboratory activities which are 
conducted in rural districts are as follows : 

1. The examination of cultures and specimens derived from the 
human body for the purpose of detecting bacteria of disease. 

2. The examination of sewage for disease germs and decaying matter, 
chiefly to determine the degree of its purification. 

3. The examination of water for its purity and the presence of 
substances of human origin. 

4. The examination of milk for bacteria as an indication of its fresh- 
ness and wholesomeness. 

5. Giving advice regarding remedies for the conditions which are 
found. 

6. Preparing vaccines, serums, and antitoxins for the prevention and 
cure of disease. 

There are twenty-eight reportable diseases in New York State and 
the laboratory is of direct assistance for diagnosis or prevention or 
treatment in all except six — chicken-pox, German measles, measles, 
mumps, scarlet fever, and trachoma. A diagnosis of all the others 
except poliomyelitis and smallpox may be made by finding their special 
disease germs in the excretions or blood. 

Curative serums are prepared for anthrax, cholera, diphtheria, 
dysentery, epidemic cerebrospinal meningitis, gonorrhea, plague, 
pneumonia, and poliomyelitis. Vaccines or other similar substances 
for prevention or cure are prepared for cholera, diphtheria, dysentery, 
paratyphoid fever, plague, rabies, smallpox, typhoid fever, and 
whooping-cough . 

Bacteriological examinations are extremely sensitive methods of 
detecting disease germs, and the question often arises regarding the 
meaning of the laboratory reports when the bacteria produce no per- 
ceptible effects. There is danger on the one hand of arousing an 
unreasoning fear of all bacteria, and, on the other, of minimizing the 
necessity of all precautions, since a person may be healthy and still 
harbor bacteria which are virulent to others. Carriers are detected 
only by means of a laboratory examination, and their control is often 
peculiarly difficult in rural districts where the subject is new to the 



PUBLICITY AND EDUCATION 577 

people and is seldom mentioned in newspapers and periodicals. Each 
report must be considered by itself and the case to which it applies 
must be handled after a full consideration of all phases of the question. 

PUBLICITY AND EDUCATION. 

Success in public health work depends on the cooperation of the 
people and on their knowledge of the methods and objects of the activi- 
ties of departments of health. Stubbornness and hostility are usually 
due to ignorance and are overcome by education. The health depart- 
ments of the several States and of the larger cities carry on extensive 
work in publicity and education. The promotion of this work is espe- 
cially important in the country owing to the absence of the educational 
advantages of the city. People are naturally about a generation behind 
advanced public health workers in their knowledge of modern medical 
subjects. One of the great objects in public health education is to 
make the knowledge of modern sanitary methods and discoveries imme- 
diately available to the general public. 

People usually get their knowledge of public health matters largely 
from tradition. They call ever}' kind of infection a cold after the 
manner of their fathers, and believe in the efficacy of a change of air 
for the most varied ills. These old notions are often confirmed by 
physicians, especially those who ended their study of medicine when 
they graduated from college. People get sanitary and hygienic, ideas 
from newspaper articles which are planned from the standpoint of 
news rather than of medicine, and are often written by editors who 
know hygiene as slightly as their re ders. Instruction is given in 
sanitation in public schools, but the teachers themselves are years 
behind the advanced knowledge of physicians. The reports and 
publications of departments of health are also popular sources of 
knowledge in hygiene. But in addition to all these means departments 
of health must do educational advertising which will influence the 
people to vote taxes for the support of public health work. "Public 
health is purchasable" is the motto of the Xew York State Department 
of Health. Whether or not people will place a money value upon 
health will depend largely upon their knowledge of the accomplish- 
ments and aims of the departments of health. 

The methods which a rural department of health may adopt in its 
publicity and educational work are: 

1 . Private explanations by the health officer. 

2. Newspaper publicity. 

3. Formal reports. 

4. Lectures. 

5. Posters and handbills. 

6. Exhibits. 

7. Campaigns for special objects. 

The most effective educational work is that done by the health officer 
himself in the discharge of his official duties. Every case of communi- 
37 



578 RURAL PUBLIC HEALTH WORK 

cable disease which he isolates affords an opportunity to instruct the 
whole household regarding the nature of the disease, the precautions 
to take, and the methods of its isolation. Every complaint which he 
investigates or nuisance that he inspects is a subject for a short talk 
on its sanitary bearing. The audience will be far larger than those 
who actually hear him, for his words will be quoted to the neighbors 
and his ideas will be favorite topics for discussion in the whole neigh- 
borhood for days afterward. The advantage of this method of impart- 
ing knowledge is that the subject is something in which the people are 
vitally and immediately interested. A health officer neglects one of 
the greatest of his opportunities if he fails to take time to instruct the 
persons whom he seeks to control. 

A second method of reaching the people is by means of the country 
newspapers. A rural paper reaches practically every person in a town- 
ship and every personal item is noted. Health officers and public 
health nurses are usually modest in talking and avoid personal adver- 
tising, but they are also public officials and have a duty to inform the 
people regarding public health affairs just as a private physician is 
expected to inform the family regarding a sick patient. An efficient 
health officer will be a standard source of news for an editor, and in 
return the editor will be disposed to give publicity to the plans of the 
health officer and to support his policies. A health officer may properly 
give to a reporter accounts of the work which he does, interviews on 
timely subjects, articles of information on matters before the people, 
and the formal reports which he makes to his board of health. 

One reason that the people often do not realize the importance of 
public health work is that the health officer does not take the trouble 
to make written reports to his board of health. The fact that a report 
is in writing makes it available as an educational document. The 
confidence which the people feel in a department of health depends 
largely on the formal reports which reach them. 

Lectures on public health topics are also of great value in instructing 
the people. Societies and organizations are often anxious to promote 
lectures on a subject which is popular and timely, and the services of 
well-known lecturers can usually be obtained from the departments 
of health of the cities and States. 

Posters and handbills are valuable in informing the people regarding 
matters of immediate interest to the people. They can usually be 
distributed to every home by means of school children. 

Exhibits are often sent out by State departments of health and 
philanthropic societies. They usually consist of charts, lantern slides, 
moving-picture films, and apparatus used in public health work, and 
may be obtained for a few days at a time. 

Campaigns are often conducted to secure special objects, such as the 
formation of a sewer district, the establishment of an infant welfare 
station, or the employment of a public health nurse. A campaign 
usually includes all the methods of publicity and education that have 
already been mentioned, 



RECORDS AND REPORTS 579 

It is important that an explanation, or a newspaper article, or a speech 
shall be given in words that the people can understand. Technical 
words such as physicians use among themselves are almost meaningless 
to the public and have no appeal even when the people are educated 
in other matters. But when public health is presented in simple words, 
its meaning may be grasped without effort and the thought readily 
sinks into the minds of the readers or hearers. 

RECORDS AND REPORTS. 

One of the sources of weakness of a rural health department is usually 
the meagerness of its records. A health officer can usually do his field 
work without keeping records or making formal reports. He usually 
has few items in any one line of work and can readily carry them in 
mind until the work is accomplished. Yet if each item were recorded 
as is done by officials in a city or State department of health, the total 
would probably surprise the health officer and the public. 

Records and reports are necessary in order to inform the public of 
the work of the health officer and to arouse the interest of the people 
in public health matters. They are absolutely necessary in order to 
enable a board of health to form an intelligent budget. They are also 
extremely desirable on account of their effect on the health officer 
himself. They compel a health officer to state the problems which 
come before him and to see himself as others seen him. A problem 
clearly stated is half solved. Many things which at first seem important 
and annoying are seen to have no foundation when they are described, 
and many that seem trivial assume importance when they are con- 
sidered in writing. 

The records and reports which a ruraJ health officer may profitably 
make are as follows : 

1. A diary. 

2. A note book. 

3. A permanent record book. 

4. Reports on special work. 

5. Regular reports, monthly or annual. 

Records of field work are necessary for the protection of the health 
officer himself and of the municipality which he represents. If the 
legality of his acts should be questioned and he should be compelled 
to defend himself in court, his written records will be the most valuable 
evidence that he can present. The New York State law is that the 
records are presumptive evidence of the facts to which they relate. 
(Public Health Law, Section 21-b.) 

A diary would correspond to the daily visiting list of a physician 
and would be evidence of the dates of his visits and inspections. A 
health officer could use the diaries on the witness stand to refresh his 
memory even if the entries are meager and are meaningless to other 
persons. 

A note-book would contain brief outlines of inspections, descriptions 



580 RURAL PUBLIC HEALTH WORK 

of unsanitary conditions, and histories of cases of contagious diseases. 
Notes made while a health officer is making an inspection are the 
strongest kind of evidence that he can present. A note-book would 
correspond to a day-book of a shopkeeper. 

The Department of Health of New York State has devised a per- 
manent record book for the use of health officers. It contains pages 
for the following records: 

Communicable diseases. 

Complaints and nuisances. 

Registration of deaths without medical attendance. 

Commitments for insanity. 

Inspections of public buildings. 

Milk dealers' permits. 

Expenses. 

Supplies received and delivered. 

Miscellaneous. 

When a health officer makes a special investigation of an epidemic 

or complaint or other condition, it is his duty to make a written report 

of his findings to the board of health or other authoritative body. A 

standard form of report contains the following items in the order given: 

1. Name the condition under investigation and state the particular 
reason for making it. 

2. State specifically the time and place of making the investigation 
and name the persons consulted. 

3. Describe the conditions that were found. Include names, 
addresses, dates, and accurate figures if possible. 

4. State the advice which was given and the official action taken. 

5. State the attitude of the person responsible for the condition and 
the likelihood of his compliance with the directions that were given. 

The object of the report is to give a complete description of the con- 
dition, so that a board of health or court may readily understand its 
nature and the official action that was taken. 

The regular reports of a health officer may be compiled from the 
permanent record book, if one is kept. A monthly report will be prin- 
cipally statistical. The form used by the State Department of Health 
of New York contains the following items. 

1. Communicable diseases. 

2. Special conferences attended. 

3. Hours devoted to health matters. 

4. Amount of money audited by the board of health. 

5. Public buildings inspected. 

6. Premises cleaned, renovated, disinfected. 

7. Dairies scored. 

8. Permits issued. 

9. Lectures given. 

10. Board of health meetings attended. 

1 1 . Complaints received, investigated, satisfied. 

12. Sanitary inspections made. 






SANITARY SURVEY 581 

13. Laboratory supplies issued. 

14. Other items of work. 

15. Remarks and explanations. 

An annual report will be both statistical and descriptive, and will 
include a discussion of the following items : 

1. Communicable diseases. 

2. Vital statistics, especially deaths and births. 

3. Complaints and nuisances. 

4. Dairy inspections. 

5. Water supplies. 

6. Sewage disposal. 

7. Garbage disposal. 

8. Suppression of flies and mosquitoes. 

9. Midwives. 

10. Public health nursing, including child hygiene and infant welfare. 

11. Anti-tuberculosis work. 

12. Laboratory supplies. 

13. Educational work, lectures, newspaper articles, and exhibits. 

14. Expenses and budget. 

15. Lay organizations cooperating with the health officer. 

16. A plan for the coming year, especially a specific object on which 
special stress will be laid. 



SANITARY SURVEY. 

A health officer is expected to be familiar with the sanitary condi- 
tions in his district. A form for a sanitary survey required by the New 
York State Department of Health contains the following items: 

1. Population, total; by age; by race; foreign born. 

2. Topography, soil; natural waters. 

3. Financial expenditures. 

4. Water supply; sources; purity; records of analysis; recommenda- 
tions made by State Department of Health. 

5. Sewage disposal; sewage districts; sew T age connections; cesspools; 
privies; relation to wells. 

6. Disposal of other wastes; garbage; manure. Local ordinances 
regarding them. 

7. Nuisances; the nature of the principal ones; factory wastes. 

8. Public streets ; accidents at railroad crossings. 

9. Buildings; tenement houses; building regulations; bath rooms; 
public buildings inspected regularly. 

10. Schools, number; special provision for tubercular children; 
medical inspection of babies. 

11. Hospitals; provision for general cases; for contagious diseases; 
for tuberculosis. 

12. Labor camps; their number and character; sanitary condition; 
permits issued. 



582 RURAL PUBLIC HEALTH WORK 

13. Summer resorts; inspections made; provision for milk; waste 
disposal; sewage disposal. 

14. Barber shops ; their sanitary condition. 

If). Dairies; number; average score; licensing; general character of 
milk supply. 

16. Special sanitary code regulations (common towels, common 
drinking cups, spitting, midwives, etc.). 

17. Educational work; lectures; number of people reached; confer- 
ences attended by health officer; other educational work. 

18. Miscellaneous (board meetings, hours devoted to public health 
work; assistants; annual reports; lay societies assisting the health 
officer; record book; tuberculosis register. 

19. Conclusions; special needs of the district (public health nurse, 
other assistants; more money; laboratory facilities; cooperation from 
the board of health; pure water supply; sewage system; educational 
work; improved milk supply, etc.). 

STATUS OF A RURAL HEALTH OFFICER. 

A health officer is the medical advisor of a municipality and his 
relation to a community is the same as that of a trusted physician to a 
family. He is an all-round practitioner of public health medicine and 
his standing with experts will depend upon the same personal factors 
that determine the reputation of a family physician with specialists 
in medicine and surgery. Hundreds of rural health officers are doing 
a high grade of work which merits the confidence of the best experts 
in the departments of health of States and large cities. Health officer 
work is becoming standardized and ennobled, and its practice is a 
worthy ambition for the best medical talent in a community. 



CHAPTER XXIIL 

TROPICAL HYGIENE. 

By M. E. CONNOR, M.D. 

CLIMATE. 

Meteorology treats of climate and weather. 

Climate may be tropical, semitropical, temperate, mountain or marine 
and is dependent in the main upon (1) distance from the equator, 
(2) height above sea-level, (3) distance from the sea, (4) direction of 
prevailing winds. The tropical climate is one of constant high tempera- 
ture, relative humidity, intensity of light, increased electric tension 
and actinic action of the sun. A climate cannot be considered 
unhealthy because of high temperature alone, the relative humidity 
is the important factor in preventing the white race in adaptation to 
tropical environments. 

Weather, is a term to designate the condition of the atmosphere with 
reference to wind, pressure, temperature, water-vapor as humidity, 
clouds, precipitation and evaporation, electricity. 

Temperature. — Climate and temperature are largely controlled by 
the water-vapor in the air, rainfall, distance from ocean currents, 
altitude, movement of air and the presence or absence of vegetation. 
Coast areas will have a more equable temperature than inland localities. 
The body temperature is regulated by an nervous mechanism and the 
temperature is prevented from rising through the dissipation of excess 
heat by sweating and by radiation, conduction and convection. 

Air is a mixture of the gases, O and N, water and varying amounts 
of carbonic acid gas and a small amount of solid matter. The body 
needs all the air it can get, especially in the tropics there is never any 
danger of receiving too much air into the body. Modern medicine 
strongly urges open-air treatment in diseased lungs and certain other 
ailments. 

Air is rendered impure by: 

! carbonic acid, 
dead tissue, 
bacteria 
hydrogen sulphide gas. 
1 decaying vegetable matter, 
particles of dirt. 

3. By dust j excrement. 

sputum, etc. 
coughing. 

4. By bacteria \ sneezing. 

expectoration. 



584 TROPICAL HYGIENE 

The air space Deeded by an individual will depend upon several 
factors as, nature of work, location, whether in a factory or dwelling. 
It is a fairly fixed principle that a 1000 cubic feet of air space be allowed 
each person and at least 3000 cubic feet of air every hour. 

The air is purified by the following natural agents: 

1. Sun. 

2. Plants. 

3. Winds. 

4. Rain. 

The sunlight is the master sanitarian in the tropics, it kills most of 
the germs in the air and wherever it penetrates it disinfects. 

The plants absorb carbonic acid gas from the air and return oxygen. 

The winds distribute the air and thus make uniformity in composition. 

The rain is a purifier by carrying down suspended particles of dust, 
etc. 

WATER AND WATER SUPPLIES. 

The purity of water is an essential that cannot be ignored in the 
tropics if one is to escape the many diseases in which water may be 
the vehicle of transmission. The customs of the natives are such that 
they can never be depended upon to safeguard the water supply either 
at the source or in the home, and the safest course for the foreigner to 
follow is to exercise constant supervision over the water that he and 
his family use. 

The supply of water either directly or indirectly comes from the 
rainfall — it may be from wells, springs, ponds, surface water or collected 
from roofs and stored in tanks. The water in the stream may be as 
clear as crystal and be heavily contaminated by disease germs and 
parasites, due to the custom of the natives of defecating on the ground, 
whence the feces are scattered by animals and carried by the rain into 
streams. 

In some countries the natives defecate on the banks of streams and 
into the stream itself. Tropical climate and native customs are ideal 
for keeping alive in a community many diseases which with higher 
sanitary standards would be eliminated (in temperate regions the con- 
ditions are not so favorable for germ life). 

It should be a fixed principle with the foreigner in the tropics never 
to drink raw water, no matter how clear it may be, and no matter how 
free from possible pollution the surroundings appear to be. 

Water not only carries the germs of typhoid fever, dysentery and 
cholera but sometimes is the vehicle of transmission for the exciting 
cause of ulcers, ringworm, itch, etc. 

The easiest method of treating water is by boiling; and to be thor- 
oughly sterilized the water should be allowed to boil for twenty minutes 
then allowed to cool, properly covered, after which it can be placed 
in bottles and sealed. Filtration is a reasonably safe method when 
germ-proof filters are used; the ordinary filters on the market can only 



FOOD 585 

remove gross material and does not prevent germ life from passing 
them. The modern community plants use liquid chlorin to kill germ 
life in water. 

FOOD. 

The function of food is to replace body tissue and supply energy. 
New tissue is formed and old tissue repaired, and is accomplished by 
that part of the diet that is assimilated. This important function can 
only be secured by a balanced ration. 

Food is divided into five classes : 

1. Proteins. 

2. Fats. 

3. Carbohydrates. 

4. Salts. 

5. Water. 

1. Proteins or Proteids. — Proteins or proteids are tissue builders and 
repairers and form the chemical basis of all living animal and vegetable 
cells. They regulate oxidation, are heat producers and form fat. 
The body demands a daily fixed amount of proteins which are not 
dependent upon the work done, as is the case with fats and carbo- 
hydrates. Proteins are not stored in the body and any excess must be 
used up and eliminated, chemically all proteins consist of oxygen, 
nitrogen, hydrogen, sulphur and frequently phosphorus. 

2. Fats. — The function of fats in the body is the formation of fat 
and the production of heat and energy. The end-products of the fats 
are carbon dioxide and water. Any excess of fat is stored up for the 
future needs of the body. Fats are nitrogen-free, being chiefly made up 
of hydrogen, carbon and a small proportion of oxygen. 

3. Carbohydrates. — Carbohydrates act in a similar way to fats, sup- 
plying energy and heat to the body. They are made up of hydrogen, 
oxygen and carbon. All carbohydrates are absorbed as sugar. 

4. Salts. — If there is a deficiency of salts in our dietary a state of 
malnutrition soon results. The salts of vegetable acids found in fruits 
and vegetables are a necessary part of a ration. Common table salt is 
the chief mineral element and is absolutely necessary to the blood and 
tissues. Without sufficient common salt there can be no digestive 
actions by the salivary juice nor chlorin for the hydrochloric acid of the 
gastric juice, nor could the carbohydrates or nitrogenous compounds 
be properly digested. The fact should not be overlooked that many 
persons eat too much salt, and this is especially an evil if there is any 
tendency to gout or puffiness of the ankles in the later afternoon. 

5. Water. — The average person consumes two and a half pints to 
four pints of water daily. Water is an absolute necessity of life; it 
does not undergo any change itself in the body, but its presence is a 
necessity for the chemical changes that take place in other foodstuffs. 

The white man in the tropics must avoid the tendency to over- 
indulgence. There is already a heavy enough strain on the body organs 
without adding by consuming too much animal food. 



586 TROPICAL HYGIENE 

The usual custom of the foreigner is to take a light breakfast, con- 
sisting of fruit, toast and coffee, just before leaving home. Lunch is 
served between 12 and 1 o'clock, and is usually a substantial meal, 
consisting of fish or meat, vegetables, fruit and refreshments. The 
dinner meal served in the evening is similar to lunch. The longer a 
person remains in the tropics, working under average conditions, the 
more simple the meals become. It is a mistake to eat more than three 
meals a day and a wise plan to eat only when hungry. 

CLOTHING. 

The clothing used in the tropics must be permeable to air and allow 
of the free exchange of gases; it should be porous enough to permit air 
to the body and the free passage of carbon dioxide gas which is con- 
stantly being excreted by the skin. Woolen flannel is the most per- 
meable of textile material, and linen the least; wool absorbs more than 
silk, cotton or linen. 

The best absorbing power of garments depends upon the color and 
not upon the texture; white absorbs least, then khaki, olive-drab, 
green, red, brown, blue and black; thus white is the best for outdoor 
wear in hot weather. 

Underclothing. — Thin woolen material is probably best for underwear 
in the tropics; the objection to wool is the irritation and care necessary 
in washing to prevent shrinking. 

Silk possesses all the qualities of wool, but in very warm weather it 
becomes sodden w T ith sweat and is then a too good a conductor of heat 
to be of real service in the tropics. Cotton fabrics are more generally 
used in the tropics for underwear, shirts, pajamas, etc. The use of the 
abdominal belt of woolen or flannel will be found to be of very great 
service, especially by those having a tendency to intestinal disorders. 
It should always be remembered that clothing when damp or wet 
becomes a good conductor of heat, and the risk of remaining in damp 
clothes should never be lost sight of. 

Outer clothing. — The outer clothing should be as light in weight as is 
possible and of white or khaki in color, white reflects the heat and 
absorbs very little but the chemical rays of the sun pass readily through 
it. The so-called solar fabrics have a white outer surface and a black- 
red or orange on the under surface. Red and orange absorb the 
chemical rays. 

Head Covering. — The white or khaki colored taupee is ideal for the 
tropics. It should be well ventilated and this is done from below with 
an internal band so arranged that the head does not touch the frame 
of the hat. The helmet should have a broad brim lined with green and 
it is better to prolong the brim down the back of the neck. The 
neck extension of the helmet should be lined internally with red, yellow 
or black. 

It has been recommended that when white men are compelled to 
work under the tropical sun and have their backs exposed to the sun's 






HOUSES 587 

rays that they sew into the shirts along the spine a strip of yellow and 
red or black silk. Blondes stand the tropical climate as well as bru- 
nettes, everything considered. 

The intense glare may cause eye smarting and strain and should be 
overcome by glasses. 

To sum up, white clothing is the coolest and black the warmest. 
Clothing should be as light in weight as is possible, and loose fitting in 
order that the heated air may arise from aroimd the body. Wet and 
damp clothing takes the heat out of the body and should be changed 
for dry as soon as is possible. 

Clothing at Night. — While sleeping the heart-beats lessen and there 
is not the heat made as when the person is moving around, and the 
body unless covered will become chilled, this chilling causes the body 
resistance to be lowered and opens the way for colds, pneumonia, 
intestinal disorders, etc. 

HOUSES. 

There are three factors that should guide in providing a home in 
the tropics; (1) site, (2) construction, (3) ventilation and (4) drainage. 

1. Site. — The site selected for a dwelling should be elevated and on 
sloping ground and as far as possible from the native village. Clay 
soils are to be avoided as they are usually damp. Sandy or gravel soils 
are the most desirable and more especially if covered by short grass. 

2. Construction. — The tropical dwelling should be constructed of 
non-conductor material such as hollow-tile, concrete block with center 
air space, treated brick or mud. The frame house is most frequently 
seen in the tropics, and this fact does not mean that the wooden struc- 
ture is the- most desirable, on the contrary they are more expensive 
over a term of years and maintenance much greater than buildings of 
solid construction on account of ravages of insects, such as wood eating 
ants, and rapid deterioration in the wood from exposure to high tem- 
perature and heavy rains. In most sections of the tropics today the 
permanent buildings, that is to say, structures to be used for a period 
of over five years, are being constructed of solid material. All dwellings 
should be planned w r ith foundation pillars or walls of solid material 
to prevent rotting, moisture absorbing and as a measure against rats 
finding a resting place under ground floor when that is of concrete. 
The foundation walls where the first floor is to be of concrete should 
be settled into the ground to a depth of at least 18 inches. 

The two storied house is far more preferable than the bungalow, 
there is a monotony in cooking, eating, living and sleeping on the same 
floor level. Ample verandah space on all floor levels should be provided 
and the verandah should extend all around the building. For sanitary 
reasons it is advisable that dwellings be elevated above the ground, the 
height will vary with the contour of the surface, but in any event the 
distance from the surface of the ground to the lowest sills should be 
such as to admit of free and easy inspection of the area and for the free 
passage of light and air. Bungalows may be elevated to a height of 






588 TROPICAL HYGIENE 

seven feet and the surface of the ground concreted and the space used 
as a wash and dry room in the rainy season. 

)>. Ventilation. — All dwellings should be so constructed that air 
currents can pass through the building. Every room should permit 
of its being - Hooded by sunlight. Doors and windows should be arranged 
so that there will be a movement of air naturally and not dependent 
upon the use of mechanical devices to create a change of air. 

4. Drainage. — No building in the tropics should have roof gutters 
unless they are absolutely necessary for the collection of water, for the 
simple reason that all gutters sooner or later sag and retain debris and 
invariably become mosquito breeding places. Concrete drains on the 
surface of the ground in line with roof edges and graded to the street 
drain will handle satisfactorily all roof water and prevent accumulation 
in the yards. Damp areas due to seepage can be made dry by installing 
subsoil pipes. Tropical homes built on correct lines and by this is 
meant that particular attention has been given to the details of location, 
light, ventilation and drainage have met the first and most important 
requirement for the proper colonization of the white men in the tropics. 

DISPOSAL OF REFUSE. 

No dwelling can be called complete unless provided with some 
sanitary method for disposal of refuse matter and body evacuations. 

Refuse matter may be classified as excreta and refuse. The safe 
disposal of excreta is the more important and will be considered in 
detail. Some religious sects enjoin their people to bury all body 
evacuations and if this were properly carried out by all peoples many 
soil pollution diseases would be eradicated. 

The following methods of disposal of excreta for homes in the 
tropics have been recommended where a modern sewer system cannot 
for any reason be installed, i. e.\ 

1. Septic tank. 

2. Receptacle, i. e., bucket or pail. 

3. Incineration. 

4. Pit. 

5. Canals. 

1. Septic Tank. — Septic tank or biological treatment is dependent 
upon the action of organisms which liquify and render inodorous the 
feces received into the tank and are very satisfactory when properly 
constructed and located. The septic tank principal can be adopted to 
serve large concentrated communities. 

2. Receptacle. — The bucket, tin or tub system requires a collection 
service that is difficult to maintain at a satisfactory point of efficiency. 
The labor ordinarily available for this work is not dependable and con- 
stant supervision is absolutely necessary in the collection and disposal 
of the material. The receptacle system of excreta disposal is a reason- 
ably safe method when properly carried out but is almost always looked 
upon as a temporary measure. 






INSECTS AND DISEASE 589 

3. Incineration. — The disposal of excreta by burning is a safe method 
and may be accomplished by the open fire or in specially constructed 
incinerators. 

4. Pit Privies. — Pit privies are frequently the only practical method 
for excreta disposal in the tropics, and are satisfactory when properly 
located with drainage away from the water supply, and constructed 
so that flies and mosquitoes will not find a breeding and harboring 
place in the vault. 

The depth of the privy will depend upon the sub-water level and the 
number using the pit. Where the soil is firm the pit may be sunk to 
great depths and it will be found advantageous to allow a depth of twenty 
feet or more; pits at this depth will not, as a rule, become fly breeding 
places because the sunlight will not reach the contents of the pit. The 
selection of a breeding place by flies appears to be determined in some 
way by the amount of sunlight reaching the area. 

If a shallow pit has been determined upon the depth should be 
not less than eight feet, and it is suggested that a layer of stable manure, 
about four inches in thickness, be spread at the bottom of the pit to 
hasten nitrification of the fecal contents. 

The ventilation of all systems of excreta disposal is an essential, for 
the pit type the flue must be carried into the vault for a distance of at 
least three feet and preferably five feet and above the superstructure 
for three or four feet. Every pit privy should provide a small seat for 
children. 

5. Canals. — In coast towns it is sometimes more economical to 
handle excreta disposal by constructing a series of canals which connect 
with the sea. If the drains are graded properly, the sides are kept free 
of grass and debris and the outhouses placed in such a manner that the 
feces are received fairly in the center of the canal, the results are satis- 
factory and maintenance charges almost nil. 

It should be remembered that any system will require supervision, 
and the best method of excreta disposal for any community can only 
be arrived at after a thorough study of conditions affecting the com- 
munity. It is unwise to make a snap recommendation which cannot in 
some instances be championed if challenged. 

Refuse disposal, such as household refuse, stable and street sweepings 
and general litter are best disposed of by burning in the open fire or in 
an incinerator. The sanitarian's problem in the tropics is to train the 
people to place refuse in cans or boxes for collection. They are so 
accustomed to depend upon the buzzard, hog, dog or fowls to dispose 
of same that it is only by a system of fines and punishments that they 
can be taught to use garbage receptacles. 

INSECTS AND DISEASE. 

Aside from acts of God manifested as devastating earthquakes, 
floods, droughts, etc., the struggle of the human race, and more espe- 
cially the white race, to maintain a foothold in the tropics has ever 



590 TROPICAL HYGIENE 

been a contest with insect life. The tropical conditions are especially 
favorable through the year for the propagation and development of 
some form of insect life, together with a great area so sparsely settled 
that it is not to be wondered at, in the light of our present knowledge 
of disease transmission, that the human has been forced at times to 
abandon fertile areas on account of certain diseases the organisms of 
which we know is spread by insects. 

Some species of insects enter into the daily life of all human beings, 
they live in most intimate contact with us in cleanliness and filth, and 
we are dependent upon some for certain necessary articles; witness the 
insects that produce honey, beeswax, silk, etc. 

Insects may transmit disease germs in three ways, i. e. : 

1. Intermediate host. 

2. Mechanical. 

3. As a vehicle. 

1. The mosquitoes, fleas and ticks are hosts for disease-producing 
organisms that may or may not undergo changes or further develop- 
ment in the host. 

The mosquito is the sole means of transmission of yellow fever, 
malaria, dengue and filariasis. 
The flea transmits the B. pestis. 
The tick transmits the spirocheta of relapsing fever. 

2. Mechanical transmission is affected by the fly, ant, cockroach 
and any insect or animal that feasts on or inhabits fecal matter, gar- 
bage, contaminated articles as in a sick room, and later has access to 
man's food and water supply and to his person. 

3. As a vehicle it has recently been shown that the digestive fluid 
of the common house-fly is a favorable medium for the growth of 
tubercle bacilli and this germ has been found in great numbers in the 
fly's droppings. The germs of enteric fever and cholera grow and multi- 
ply in the intestines of the fly. These organisms do not appear to injure 
their host which is different from the action of the Bacillus pestis on 
the flea. 

It is reasonable to assume that all blood sucking insects and animals 
are possible carriers of disease. Germs and a study of their habits and 
life-cycle should be made in order to intelligently combat them. 

The insects known to be active agents in the transmission of disease 
germs are given below: 

1. Fleas. — Plague germs are carried to humans by the rat-flea. 

2. Flies. — The common house fly transmits typhoid fever, tubercu- 
losis, diarrhea, cholera, dysentery, maggots in wounds, skin and eye 
diseases. 

3. Biting Flies. — The tsetse fly conveys sleeping sickness. 

4. Mosquitoes. — Mosquitoes transmit yellow fever, malaria, dengue 
and filariasis. 

5. Lice. — Body lice transmit typhus and relapsing fever. 

6. Ticks. — Ticks convey mountain fever, relapsing fever, and cattle 
fever. 






INSECTS AND DISEASE 591 

Bed-bugs, ants and sand-flies have been charged as vehicles of trans- 
mission of disease germs but the case has not been definitely proved 
against them. 

Tropical medicine is especially concerned with the following orders 
and families of insects : 

1. The Anoptera — lice. 

2. The Hymenoptera— ants. 

3. The Hemiptera — bugs. 

4. The Diptera — flies, biting and non-biting. 

5. The Siphonaptera — fleas. 

6. Arachnida — mites, ticks, spiders, scorpions, etc. 

The Anoptera. — This order includes three species of lice which 
infest man: 

1. Body louse. 

2. Head louse. 

3. Crab louse. 

The lice are blood-sucking insects and as such must be regarded as 
probable agents in disease transmission as a vehicle or even host. 
Recent studies indicate that the bite of the louse is harmless in itself 
and that the disease germs are conveyed when the insect has been 
crushed and rubbed into a raw surface caused by scratching. 

Destruction of lice may be accomplished with ammoniated mercury, 
kerosene, and the "nits" in the hair can be easily removed with a 
comb previously dipped in vinegar. The clothes should be treated with 
live steam and exposed to direct sunlight. The hair of the axilla, 
groins, etc., should be shaved. 

The Hymenoptera. — This order includes the stinging insects, i. e., 
ants, bees and various worms. There is no conclusive evidence that any 
of these insects convey disease germs, but the habits of certain ants, 
for instance, suggest the possibility of this and warrants their being 
placed in the suspicious class. 

The Hemiptera. — There are several families of bugs which under 
ordinary conditions are inoffensive, but at the same time are capable 
of inflicting painful wounds. 

The specie concerned in the spread of disease is the bed-bug, and it 
has been charged as a disseminator of leprosy, kala-azar, yaws, tuber- 
culosis and skin diseases. 

The bed-bug must have a feed of blood before each moult and before 
egg-laying; if the blood is not available the moult is delayed. It is a 
slow feeder, taking about fifteen minutes to complete a meal, and 
feeds every twenty-four to thirty-six hours. 

In addition to be a probable spreader of disease the bed-bug is a 
nuisance, and is only found in dwellings where cleanliness is not given 
first consideration. 

The Diptera. — This order includes mosquitoes, sand-flies, midges and 
house-flies. 

Mosquitoes. — The culicinse transmit dengue and filaria. 
The Ades calopus transmit the virus of yellow fever. 
The Anophelinse transmit the organism of malaria. 



592 TROPICAL HYGIENE 

In each instance it is the female that does the biting. It needs blood 
and must have it before ovipositing. The male never bites and sub- 
sists on vegetable juices. The first three stages of the life cycle are 
spent in water, i. e.: 
1- Egg. 

2. Larvae. 

3. Pupa?. 

Mosquitoes differ markedly in their habits, the calopus is essentially 
a domestic mosquito and usually spends its entire life near the place 
it matured. The culex will breed in almost any collection of water, 
as marshes, pit privies, wells, stagnant pools, etc., and are great 
travelers. The anophelinse select quite shaded collections of water 
in which aquatic plants and animal life abound, and upon these the 
larva? feed. 

The time of development of the mosquito from egg to adult will 
vary with the temperature, but the average time is about ten days. It 
is recommended, however, that in order to destroy early maturities 
mosquito brigades be organized with the view of covering the area, 
in which a mosquito eradication campaign is being conducted, in 
seven days. The anopheles will breed in brackish water when a more 
favorable place is not available. The anopheles is not ordinarily a long- 
distance flier, but it has been proved that a flight of over a mile is not 
unusual, and this fact should be kept in mind w T hen estimating the cost 
of an antimalarial campaign. 

The following measures if consistently carried out will rid a com- 
munity of mosquitoes: 



1. Reduction of number of 
infected humans 



2. Bite prevention 

3. Antilarva? measures 



daily dose of quinine. 

mosquitoes at night, 
screened houses. 

chemicals to exposed parts of body, 
drainage, training streams, 
filling, grass cutting, 
oiling, collection of containers, 
water and sewer system. 
4. Sanitary works \ paved streets. 

concrete drains. 

Of the above measures the following have been placed in the order of 
their importance for communities where a complete organization can 
not be developed for the early days of the campaign of mosquito 
reduction : 

1. Drainage. 

2. Grass-cutting. 

3. Bite prevention. 

4. Reduction of infected humans. 

Sand-flies. — There are two classes of winged insects known as sand- 
flies, i. e., Simulium or Buffalo gnat and the Phlebotomus or owl midge. 



INSECTS AND DISEASE 593 

In each case it is the female that bites and seeks blood, the male being 
harmless. 

The Simulium breed in swift-running streams and the Phlebotomus 
in damp earth and in the dejecta of lizards. 

These little flies are believed to be the agents in the transmission 
of certain tropical fevers. The Buffalo gnat causes great damage to 
cattle by attacking the eyes, ears and nose. 

The following measures have been suggested to combat these flies: 

1. Good walls and floors in dwellings, all cracks and separations to 
be filled by putty, wax or similar material. 

2. Painting the walls and floors; whitewashing is not satisfactory. 

3. All interior woodwork to be painted once every year. 

4. The use of a fine mesh mosquito bar while sleeping. 

Midges. — Midges are blood-sucking insects, and in addition to 
making life miserable when present in any considerable numbers, must 
be looked upon as possible agents in the dissemination of disease germs. 
One species of midges is aquatic and passes the stages of development 
like the mosquito; another species is entirely terrestrial, breeding in 
garbage heaps, decayed vegetable matter, collection of rotting wood, 
etc. 

House-flies. — The common house-fly, or Musca domestica, cannot 
bite, although the popular opinion is quite to the contrary, because its 
mouth parts are constructed for liquids only. The favorite breeding 
place for this fly is horse manure, but in the absence of this material 
the fly will deposit her eggs on any decaying matter, including human 
excrement. 

There appears to be one constant requisite for the selection of a place 
in which the fly will deposit her eggs, and that is a certain amount of 
sunlight must reach the site. It is a well-known fact that pit privies 
of great depths are never troubled by flies even though the privies be 
located in the house proper, similar results are obtained when the inte- 
rior of pit privies are coated black. There are two species of the house- 
fly, the large and small; they are alike in habits, selection of breeding 
place and disseminators of disease germs. 

The Stomoxys calcitrans, or stable-fly, is a true biting fly and closely 
resembles the house-fly, and in rainy weather will invade the home in 
great numbers. Under these circumstances persons have been bitten 
by this fly and confused them with the house-fly, hence the popular 
belief that all flies bite. The time of development of the fly will vary 
somewhat, but under favorable conditions the average time from egg to 
adult can be placed at from eight days the earliest to twelve days the 
ordinary maximum. 

The Fly as a Disseminator of Disease. — The fly must be an important 
factor in the spread of disease when we consider the ease with which 
it can pass from filth collections laden with pathogenic germs and 
the complete access it has to our food and water supply, and, further, 
the desire of the fly to alight on the membranes and ulcers, there to 
start the pruning process of its legs and wings. 
38 



594 TROPICAL HYGIENE 

The role of the fly as a mechanical disseminator of germs would 
seem to have been overestimated, and this is quite probable, as the 
fly is an intermittent feeder and is inactive for some time after each 
feeding, and the probabilities are that most of the germs and parasites 
that the fly may have attached to its mouth parts and legs while feeding 
have perished before reaching a favorable medium for growth. It has 
recently been shown that the digestive juices of the fly constitute a 
favorable medium for the development of the tubercle bacillus, and 
the organisms of cholera and enteric fever multiply in its intestines. 

Preventive Measures. — The fly has many natural enemies, such as 
the common house centipede, certain ants, beetles and small mites 
that cover its body and gradually destroy it. The fly is destroyed in 
great numbers at the close of the season by a fungus. Other measures 
of prevention consist of: 

1. Screening all doors and windows. 

2. Proper disposal of all refuse. 

3. The use of sticky papers, poison papers, and traps. 

4. Cleanliness in the home. 

The Siphonaptera. — The flea consumes an enormous quantity of 
blood in proportions to its size. The rat flea lives primarily on the rat 
and only leaves it when the rodent becomes cold, and then the flea 
seeks the first warm-blooded host, it may be another rat or a human 
being, Martin has recently shown that the rat flea is itself diseased 
when it transmits the plague bacilli to man. The sick flea sucks blood 
constantly and regurgitates it, mixed with bacilli in the flea's gullet. 
The flea is found more abundantly in dirty dwellings, old buildings and 
in places which are frequented by persons of unclean habits. Species of 
flea live on dogs, cats, pigeons, poultry, squirrels, etc. 

Arachnida. — Arachnida are not true insects, they possess many 
different characteristics, the more prominent of which is their having 
eight legs, whereas the true insects have only six. The members of this 
group which affects humans in the sense of disease transmissions are : 

1. Mites. 

2. Ticks. 

1. Mites. — The itch mite causes skin eruptions, which are trouble- 
some; the mite burrows into the skin at the axilla, back of the hands, 
fingers and toes. This mite has been charged with conveying leprosy. 

The harvest mite, or red-bug, is very abundant in warm countries 
and causes intense itching, redness and swelling of the affected parts, 
and if scratched may suppurate. 

2. Ticks. — These make up the larger part of the animal kingdom 
and carry disease germs to animals and to human beings. In habits 
they resemble the bed-bug; they infest huts and camps, and during the 
day live in cracks in the floor and walls, coming out at night to bite. 
The ticks are slow feeders and can only get sufficient blood from a 
person asleep. 

The species 0. maubata is the disseminator of the spirocheta of the 
African relapsing fever; this organism is not only spread by the tick 






SOIL POLLUTION DISEASES 595 

but passes in eggs of the ticks to the larva?, and in this manner the 
adult tick is already infective. The fact that an organism can be passed 
to the eggs of an insect explains the spread of disease to great distances, 
which in many instances has been a difficult problem to solve. 



SOIL POLLUTION DISEASES. 

Filth that is not disposed of in a sanitary manner or carried to the 
sea is deposited on the ground, and in the tropics, wheie the custom 
of the natives, necessary degree of heat and moisture are present 
throughout the year it is not difficult to understand that pathogenic 
organisms and parasites find ideal conditions for multiplication. Were 
it not for Nature's scavengers, the sun, bacteria in the soil and certain 
animals, such as the hogs, buzzards, chickens and dogs, soil pollution 
diseases would have long ago annihilated the human race in the tropics, 
surely in those sections having a constant high temperature where 
these diseases are always present in more or less epidemic proportions. 
Experiments point to the fact that most animals that subsist in part 
on human excreta are immune to the effects of the pathogenic organisms, 
and most parasites contained therein, and, further, these organisms 
are apparently destroyed in the body of the host. 

The organisms causing any of the soil pollution diseases leave the 
body of the infected person in the feces or urine or both and enter the 
body via the mouth and in the case of the hookworm through the skin. 
The elimination of soil pollution diseases in the tropics resolves itself 
into the problem of the sanitary disposal of human excreta. The solu- 
tion of this problem is comparatively easy in that we know the measures 
that can be applied and get results, but the difficulty comes in the appli- 
cation of the measures due principally to lack of funds and indiffer- 
ence of the people. On the whole the soil pollution problem is less 
difficult to accomplish than the elimination of mosquitoes, as the area 
to be treated with the former is more circumscribed and the interest 
of the natives more easily awakened, as they can more easily associate 
excreta as a factor in the spread of disease than they can the mosquito. 

The principal soil pollution diseases in the tropics are : 

1. Hookworm. 

2. Dysentery. 

3. Enteric or typhoid fever. 

4. Cholera. 

1. Hookworm. — This disease was first reported from Brazil in 1864, 
it is world wide distributed and endemic in the warm countries. 

-p,, . , / Order Nematodes. 

Etlol °^ 1 Family Strongylidse. 

f Ankylostoma duodenale. 
Genus j Necator americanus. 

I Ankvlostoma cevclanicum. 



590 TROPICAL HYGIENE 

Morphology.— In the Ankylostoma duodenale the body is cylindrical 
and during life is pinkish in color. The mouth carries ventrally two 
pairs of hooked teeth and one pair dorsally. The male measures 10 
mm. in length and from 0.4 to 0.5 in width; the female measures about 
12 mm. in length and has the vulva located at the junction of the 
middle and last third. During copulation they resemble the Greek 
letter Y. The ova are ellipitical in shape, have thin shells and yolk 
segmented, size about 60 m long and 40 m broad. 

Necator americamis is the hookworm prevalent in tropical America 
in the Philippines. Recent studies indicate that this parasite is very 
widely distributed over the world. The mouth is small, no ventral 
teeth, but prominent chitinous plates and a dorsal pair of plates. The 
life-cycle of the Necator is the same as the Ankylostoma duodenale. 

Ankylostoma Ceyclanioum. — Ankylostoma ceyclanicum is the anky- 
lostome of *he cat and dog of India. It is smaller than the Ankylos- 
toma duodenale. 

Habitat. — The worms live in the duodenum and are frequently 
found in the jejunum, and fasten themselves with their teeth to the 
lining membranes and feed upon the villi. The females lay eggs in 
prodigious numbers, which leave the body in the feces, in which they 
will hatch out into larvae in from three to seven days, depending upon 
the temperature and moisture, and will moult two or more times in 
the following ten days. The larvae will remain in water for months 
and can swim and crawl on a moist surface. The eggs are not infective 
when ingested by human beings. 

Infection by the hookworm may occur via the (1) mouth or through 
the (2) skin: 

1. When the larvae are ingested they soon pass out of the stomach 
and moulting takes place up to the fifteenth day. Ova do not appear 
in the feces, as a rule, until from eight to ten weeks after infection, 
although the worms have matured and copulated in four or five weeks 
after the larvse have been ingested. 

2. Through the Skin: The larvse pierce the skin through the hair 
follicles and between the toes where the skin is tender and frequently 
cause a dermatitis, which usually disappears in a few days. 

Symptoms. — Some persons may harbor many worms without showing 
any symptoms while others will suffer grave anemia from a small 
number and death may occur from cardiac failure, exhaustion or inter- 
current disease. 

Prevention depends upon the sanitary disposal of the excreta and 
killing the parasites in the human being. The first measure calls for a 
sanitary closet and the use of the same by all persons, the second 
measure is handled by the examination of feces to locate "carriers" 
or mildly infected persons and treating those found with proper 
remedies. 

Dysentery. — This is a serious disease in the tropics and exacts an 
enormous toll each year. There are three chief types of this disease 
met with, namely: 



SOIL POLLVTIOX DISEASES 597 

1. Dysentery caused by amebse. 

2. Dysentery caused by bacteria. 

3. Dysentery caused by irritants. 

1 . Amebic Dysentery. — Amebic dysentery, may be caused by any one 
of the three species of amebse that are distinguishable under the micro- 
scope, i. e., Entameba coli, E. histolytica and E. tetragena; this later 
species is believed by Walker and Craig to be a cystic stage in the 
development of the E. histolytica. The E. coli is considered by some 
investigators to be a harmless parasite as far as true dysentery is 
concerned. 

Habitat. — Amebse are found in surface waters all over the world, 
but are especially abundant in warm countries. The organism found 
in the human has been classed as entameba and is a true parasite, but 
does not multiply outside of the body of the host. This organism is 
found in tropical surface waters in various forms. 

2. Bacillary Dysentery. — This type of dysentery has been divided 
by Hiss into four classes, the causative agent in each instance being 
closely allied bacilli, i. e., the Shiga, Hiss-Russell, Flexner-Strong and 
the Harris. The organisms can be differentiated by agglutination 
and fermentation tests. 

The Shiga bacillus is found in the stools of cases of B. dysentery 
more frequently than the other types of organisms. B. dysentery is 
usually the epidemic dysentery of armies and at times the disease 
becomes highly infectious. 

3. Dysentery Caused by Irritants. — This is the so-called catarrhal 
dysentery and may be caused by bad food, purgatives, intemperance, 
etc. 

Prevention. — Dysentery follows the ingestion of contaminated 
foodstuffs, or drinks of feces which contain the causative organism. 
It may be water-borne or carried by flies and other insects, and by 
direct and indirect contact with a person ill with the disease or a person 
recently recovered who stills harbors the organisms. 

The preventive measures consist in isolating the sick, boiling all 
water used, sanitary disposal of the feces, protection of foodstuffs and 
drink agents, flies and other insects that might have had access to 
excreta. All vegetables and fruits are safe when cooked. 

Enteric or Typhoid Fever. — Enteric or typhoid fever is one of the 
most formidable diseases in the tropics and is responsible for much 
sickness and many deaths. Typhoid attacks native and foreigner alike. 

Typhoid fever is caused by the B. typhosus and is characterized by 
continuous fever, lasting on an average of about three weeks, and a 
persistent diarrhea with the stools resembling rice water. 

The typhoid germ leaves the body of an infected in the excreta and 
urine and the new victim must take into the body via the mouth some 
of the feces or urine of an infected person. The contaminated article 
may be foodstuff or drinks, by the fingers, or from handling soiled 
linen or utensils used by the sick. 

Typhoid fever is world-wide distributed and readily assumes epi- 



598 TROPICAL HYGIENE 

demic proportions whenever conditions are favorable. Milk and 
oysters are common vehicles of transmission of bacteria in general and 
frequently of the Bacillus typhosus. 

Prophylaxis. — The problem in preventing the spread of typhoid is 
to render the carrier safe, and "carriers" are especially dangerous if 
they handle foodstuffs. Inoculation to prevent typhoid is a measure 
of prime importance and should always be carried out whenever 
practicable. Further preventive measures consist in isolating the 
" carrier," disinfecting all stools and urine, boiling all w 7 ater, prohibiting 
eating uncooked vegetables, all fruit to be washed and skin removed, 
eating only the pulp, protection of foodstuffs and drinks from flies and 
insects that might have had access to infected material. 

Cholera. — Cholera has at one time or another visited nearly every 
part of the inhabited earth. This disease is caused by the Spirillum 
cholera (Koch), or, as it is sometimes called, Comma bacillus. The 
disease is carried from person to person by direct contact, contaminated 
foodstuffs or drinks, fingers, utensils or insects, such as the fly and ant 
having access to infective material. Cholera has a case mortality of 
from 40 to 90 per cent., and rarely below 50 per cent. 

Symptoms. — Symptoms in the typical case in the incubation period 
are usually from one to tw T enty-four hours, accompanied by projectile 
vomiting and diarrhea, the stools in a short time becoming colorless, 
urine suppressed and the skin over the entire body shrivelled and 
death terminates the suffering or reaction sets in. 

The Ambulatory Type. — In the ambulatory type the symptoms are 
mild and the case passes unnoticed. These cases are a menace to 
others, as they are "carriers" and spread the disease. 

Fulminating cases are sometimes seen as a toxemia, causing death 
before the usual symptoms are manifest. 

Prophylaxis. — All discharges, including urine, from the sick should 
be disinfected and if practicable incinerated. Foodstuffs and drinks 
should be protected from flies and insects in general. Clothing and 
utensils of the sick should be sterilized and such articles that cannot be 
easily sterilized be destroyed by burning. Vegetables to be cooked and 
fruit to be thoroughly w T ashed and only the pulp eaten. 

RODENTS. 

In the tropics the most dreaded of transmissible disease is bubonic 
plague. Rats through infected fleas (Pulex cheopis and Pulex cerato- 
phyllus) are the principal agents in the spread of this disease over the 
world. In addition to the rats the squirrel and the Siberian marmot 
are known to be susceptible to plague. 

In tropical America rats and mice abound, more especially through 
the lowlands. These animals belong to the large zoological family 
Muridse of the order Rodentia, wmich is estimated to comprise nearly 
one-third of all species of mammals. The Muridse includes rats and 
mice of the genus Mus. 



kODENTS .599 

The principal species of Mus found in the tropics are: Mus musculus, 
Mus rattus and Mus norvegicus. 

Mus Musculus. — This species, the common house mouse, is found in 
large numbers in the inhabited coast regions of the tropics. It does 
not thrive well in the low temperatures of the highlands. The house 
mouse is very prolific, being sexually matured at three months. The 
number born will vary from two to eight per litter, and this sometimes 
occurs as often as ten times in a year. The house mouse is slender, the 
average weight not exceeding 17 grams, ears long and covered with 
fine hairs. The tail always long, sometimes exceeds the length of the 
body of the mouse, including the head. The color ranges from gray 
for the indoor specimen to brown for the outdoor specimen. The house 
mouse is sexually matured at three months. 

Mus Rattus. — Ship rat. Black rat. House rat. This is the common 
house rat, which has a slender body, a long tail, large eyes and ears, the 
latter being translucent. There are many subspecies of the M. rattus, 
and the principal variety found in the tropics is the M. Alexandrinus. 

Mus Alexandrinus. — Roof rat. Tree rat. The point of origin of 
this rat is not known, but is believed to be in Egypt. It is firmly 
established in the tropics, and in some sections is the dominant species. 
The roof rat is brownish-gray, average body measurement between 
15 and 20 cm., and covered with a harsh fur. Its weight does not 
usually exceed ten ounces. The tail is long and blunted. 

Mus Norvegicus. — Norway Rat. Brown Rat ("decumanus")- 
This is the most destructive rat known, the average weight being about 
fifteen ounces, but specimens are frequently trapped that exceed forty- 
five ounces. The ears are small and thickly covered with fine hair. 
The tail is long, but rarely does it exceed the combined length of the 
body and head. 

Breeding. — The constant, even temperature and abundant food 
supply which obtains in the tropics offer ideal conditions for rat- 
reproduction, and the rat population has increased so rapidly in recent 
years that the rat menace is receiving serious consideration in most 
tropical countries. 

The brown rat is very prolific, more so than the black or the roof rat. 
The female brown rat usually possesses 12 mamma?, while the black 
and the roof rat have only ten, and sometimes less. Rats may breed 
and in fact some do, in every month of the year. The usual breeding 
season is between January and June, but there is no reason why full- 
grown, healthy males should not mate at any time. The female sexual 
season is long and sometimes extends over eight months of the year. 
The period of gestation is on an average twenty-one days. The black 
rat and the Norway rat have borne litters when only eight weeks old. 

Migrations. — Rats travel long distance, either singly or in numbers, 
by themselves or are transportated in ships, trains, caravans, etc. 
When rats migrate in large numbers it is usually due to overproduction 
or shortage in food supply. In tropical America migrations on a small 
scale are sometimes witnessed just before or during an epidemic of 
bubonic plague. 



600 TROPICAL HYGIENE 

Food. — Rats differ markedly in their food habits. The Norway rat 
will eat anything and is a good scavenger. The black rat is not a good 

forager, its food must be clean, and it prefers grain. Rats feed at any 
time, and they handle their food similar to the squirrel. Any food 
eaten by man or animal serves as rat food. 

General Habits. — Rats in general have defective vision, seeing much 
better at night, and for this reason are mainly nocturnal in their forag- 
ing expeditions. Rats try to follow a beaten path in their wanderings, 
and when they lose the path, especially in a bright light, they rush 
forward until they encounter some object, and then depend upon their 
vibrissas to guide them to safety. Rats must gnaw some hard material 
at frequent intervals, in order to keep their incisors at proper length. 

The house mouse climbs and swims and jumps; it is not a voluntary 
swimmer, but performs the task very credibly when tested. It builds 
its nests in soft material in boxes, book-cases, under floors and between 
walls. 

The black rat rarely burrows but climbs trees, ship cables, electric 
wires. It is a strong jumper and swims well. The black rat consumes 
less water than other species. It builds nests principally between walls, 
ceilings and roof spaces, but rarely invades cellars or drains. 

The Norway or brown rat takes to water voluntarily and swims long 
distances. It climbs, but on account of its great weight and large size 
the task is clumsily performed. The brown rat is a very adaptable 
animal, developing in both extremes of temperature. An abundance 
of water is absolutely indispensable to the brown rat, and its nests are 
to be found in sewer drains, river banks, swamps and in houses near 
the water tank. 

All rats when hungry show cannibalistic tendencies, but under normal 
conditions most rats live in peace with their neighbor. The brown rat 
is the most ferocious and attempts, and sometimes succeeds, in killing 
or driving off other species. 

Rat Control. — This problem is usually approached through (1) rat 
prevention, and (2) rat extermination. 

Rat prevention calls for rat-proofing of buildings, which can be accom- 
plished by single walls, no attic space, concrete foundation walls 
extending into the earth for at least two feet. The first floor of a good 
concrete mixture and this overlaid with Mosaic tile. When it is ele- 
vated above the surface of the ground area should be cemented. 

Food Supplies. — These should be well protected from rats by rat- 
proofing the larder, also animal feed bins. Garbage collection service 
should be so arranged that refuse matter can be placed in proper 
receptacles and the material collected daily and disposed of preferably 
by cremation. Drains should be thoroughly cleaned out and the opens 
covered with heavy wire. 

Fumigation of ships and protection of the ships' cables by circular 
disks of not less than four feet in diameter. Wharves of wooden con- 
struction, as well as landing platforms, grain storage house, should be 
replaced with concrete structures. 



RODENTS 601 

Rat Extermination. — Rat extermination can be attempted by trap- 
ping, poisons, virus, natural enemies. 

Trapping. — Trapping is an effective measure when properly carried 
out. The snap or cage trap give good results when nicely adjusted at rat 
runs. Traps should be thoroughly cleaned after each catch, and care 
must be exercised in preventing the human or rat odor from remaining 
on the trap, and this can best be accomplished if gloves are worn by 
the person handling the traps. 

Poisons. — Bait poisoned with arsenic, strychnine, barium sulphate, 
phosphorus paste or carbon bisulphide may be used, with good results. 

Virus. — Virus to be effective must retain its virulence when placed 
in rat runs. Meat preparations now on the market lose their virulence 
shortly after exposure and are rendered harmless so far as causing any 
disease in the rat; on the contrary a rat consuming virus in less than a 
fatal dose acquires immunity. At this writing there is no proved virus 
available that will destroy rats by causing an epizootic among them 
under normal working field conditions. 

Natural Enemies. — Rats have many natural enemies, such as the 
owl, weasel, cat, dog and ferrets. 

The dog or cat with training can be very useful in any campaign to 
control rats. The Irish, Scotch and Fox terrior have proved themselves 
good ratters, their only drawback being that they cannot go into the 
runs as can a ferret. 

REFERENCES. 

Chalmers and Castellani: Tropical Medicine. 

Hinton, N. A. C: Rats and Mice as Enemies of Mankind. 

The Rat and its Relation to Public Health, U. S. P. H. S., 1910. 



CHAPTER XXIV. 

INDUSTRIAL HYGIENE. 

By LOUIS I. HARRIS, M.D. 

THE IMPORTANCE OF INDUSTRIAL HYGIENE. 

From the time when machinery was first invented, and workers 
emerged from their homes, where they had conducted their industrial 
pursuits as individual enterprises, to become a part of a complex 
industrial system, the physical welfare of the workers has as a rule been 
subordinated, if not completely ignored by factory managers. While 
hordes of immigrants kept pouring in through our gates, eager to take 
the places of those millions of workers, who, during the past several 
decades chose more attractive work or were used up, disabled, and 
thrown into the scrap heap like so many useless and worn-out machines, 
the vital necessity of conserving the health and lives of our laboring 
population was overlooked. 

While ordinarily war is a process which is destructive of human life, 
the world conflict that has just been concluded has paradoxically enough 
brought about a more widespread recognition of the need of conserving 
human life than any other event of the century. Immigration stopped, 
and the soldiers at the front were absolutely dependent upon the men, 
women and children in industry for the necessities of life and for the 
instruments of warfare. Thus it became of paramount importance 
to guard well the lives and health of the industrial army which could 
not be readily replaced. 

As industrial establishments have grown in size and complexity, 
and the sources of industrial loss and waste have come to engage the 
special attention of experts, it has gradually become recognized, not as 
a matter of sentiment or of business ethics, but from the strict stand- 
point of profit and loss, that the human element in industry is the most 
valuable one. This view is slowly winning general acceptance, and 
factory managers are beginning to give attention to industrial hygiene 
or are engaging physicians or others whose special function it is to 
prevent disease in industry, so far as possible. 

Dr. Frederick L. Hoffman 1 estimated the total number of wage- 
earners of both sexes in the United States in 1915 as 44,130,000. This 
estimate is probably more nearly in accord with conditions as they 
exist today than are the figures of the Federal Census of 1910, which 
place the industrial population at 33,500,000, and the number of 

1 Kober and Hanson's Diseases of Occupation and Vocational Hygiene, 1916, p. 777. 



IMPORTANCE OF INDUSTRIAL HYGIENE 003 

workers who annually suffer from sickness at 13,000,000. Accepting 
Dr. Hoffman's higher estimate, there must be a proportionate increase 
in the number of cases of sickness among workingmen annually. The 
financial loss through illness, which in 1910 was placed at nearly three 
quarters of a billion, must, according to Hoffman's estimate, also be 
proportionately greater. According to different investigators, an 
average of from six to nine days are lost by each wage-earner per year. 

Preventable accidents and disease are largely responsible for this 
great economic loss. If our Federal Government were arbitrarily 
to order the shutting down of industry throughout the country for a 
period of from six to nine days each year, there w T ould be a justified 
clamor and outcry against the loss it would entail; and yet, manufac- 
turers, generally speaking, are themselves virtually closing down their 
plants for from six to nine days each year because of their failure to 
check preventable sickness and accidents; their failure to adopt the 
necessary preventive measures causes a great financial loss. Not only 
do the workers suffer a monetary loss from this cause, but, in addition, 
their future usefulness to society and to their families is frequently 
greatly impaired and their lives shortened. The losses suffered by 
the combatants in the great world war were truly appalling, but the 
destructive process had a definite limit and ceased with the declaration 
of peace. An almost equally great destruction of the health and lives 
of the industrial army goes on constantly and with little appreciable 
diminution, even in times of peace. 

Omitting illness and disease, the number of accidents reported for 
the first seven months of 1917 by the Pennsylvania Department of 
Labor and Industry alone, offers striking testimony in support of the 
foregoing statements. From January 1 to August 1, 1917, the total 
number of workers in Pennsylvania who were killed in the course of 
their work, w;as 1877; 139,598 were injured. This necessitated a total 
disbursement of $4,318,992 by way of compensation for accidents and 
deaths. These figures give but a slight suggestion of the casualties 
incident to industrial activity in the country as a whole. Authoritative 
figures from many other sources might be added to show the enormous 
toll which industry takes in health and life from men, women, and 
children in industry, but those here offered will suffice to, indicate the 
magnitude of the problem. 

Industrial hygiene is one of the most recently developed branches 
of preventive medicine and has grown out of an awakening to the 
significance of conserving the lives and health of those of working age. 
It derives a special importance from considerations of a humane, 
social and economic character. 

A logical public health program demands that the attention f ocussed 
in recent years on the prevention of infant morbidity and mortality, 
shall comprehend in equal measure the protection of the adolescent 
and adult members of the community, and especially of those in 
industry. Industrial hygiene is the particular branch of public health 
medicine which does in fact concern itself equally with the protection 
of the adolescent and adult person in industry, and is thus a logical 



(>04 INDUSTRIAL HYGIENE 



extrusion of the boundaries of child hygiene. Communities lavish vast 
sums of money upon child hygiene activities up to the time that 
children end their school careers, but make little or no effort to protect 
them in shops and factories, or to provide periodic medical examinations 
for the benefit of the individual child and for the good of the State, 
once they have received their working papers. Public health activity 
that does not extend the scope of its supervision beyond the school age 
of the child shows a state of arrested development. 

Industrial Hygiene and Occupational Diseases. — Industrial hygiene 
has to do with the application of the principles of hygiene and sanitary 
engineering to the construction, equipment, and management of fac- 
tories and workshops, so as to prevent disease and injury and to pro- 
mote and to conserve the physical and mental welfare of workers. It 
is essentially a branch of preventive medicine. When the principles 
of industrial hygiene are inadequately observed or neglected in the 
work-place, diseases that are peculiarly characteristic of certain occu- 
pations may develop; these may be termed specific occupational dis- 
eases. On the other hand, the health of the worker, or the condition 
of one or more of the vital organs of the body, may be undermined by 
improper industrial conditions in such manner as to produce, or pre- 
dispose to general or local diseases of a type which, while not peculiar 
to any one occupation of those engaged in industry, may be termed 
non-specific occupational diseases. 

Too often, the term industrial hygiene is used as if it were synony- 
mous with occupational diseases. It is well to emphasize, therefore, 
that industrial hygiene applies only to measures for the prevention of 
specific and non-specific occupational diseases. Diseases of occupation 
comprise a distinct branch of clinical medicine arising out of the 
neglect of industrial hygiene. 

A factor that has persuaded factory managers of the need of protect- 
ing the health of employees, is the desire to check the ceaseless changes 
in the personnel of the working staff of large industrial organizations. 
This change, resulting from dismissals, retirements or change of place 
of employment, in the hazardous industries particularly, is at times 
so great that in order to keep up a working force of 1000 men it has 
frequently been necessary to engage from 6000 to 10,000 or more 
employees per year. This ceaseless ebb and flow in the tide of workers 
who enter and leave factories is known as the labor " turnover." The 
desire to reduce labor "turnover," by making the conditions of work 
satisfactory, is in a measure at least responsible for the installation 
of health safeguards in many establishments. 

Another factor which is stimulating the inteiest of factory managers 
in industrial hygiene is the fast growing demand for sickness insurance 
(spoken of generally as health insurance). Compensation for non- 
specific, as well as for specific occupational disease, will stimulate the 
promotion of efforts to prevent such diseases, in much the same way 
that compensation for accidental injuries and death led to the rapid 
development of the " safety first" movement. 






SCOPE OF INDUSTRIAL HYGIENE 605 



SCOPE OF INDUSTRIAL HYGIENE. 

To make industrial hygiene effective, and to prevent those diseases 
which are directly or indirectly caused by occupation, requires the 
carrying out of a comprehensive program which in its essential points 
may be briefly summarized as follows : 

1. Laws. — (a) There must be formulated definite legal standards 
to govern factory construction and operation, which are to serve as 
minimum sanitary requirements. Such laws must necessarily be based 
upon the study of conditions peculiar to various occupations, upon the 
facts ascertained from a clinical study of workers, and upon engineering 
principles w 7 hich are the result of research and which will show how to 
eliminate dangers to health arising from the faulty construction of 
buildings, machinery, equipment, and from hazardous trade processes. 
(6) Laws should be enacted granting compensation for occupational 
disease. Such laws are a most effective stimulus to efforts for the 
protection of workers. 

2. Inspection. — (a) There must be official inspection and super- 
vision of work places to ensure the maintenance of sanitary methods 
and conditions, and to discover and prosecute violations when education 
and persuasion are ineffective to bring about the correction of insanitary 
conditions. The reporting of cases of occupational disease by factory 
managers, industrial physicians, family practitioners and hospital and 
dispensary physicians should be mandatory, (b) The investigation 
of complaints pertaining to insanitary work-places or hazardous prac- 
tices is of value as a means of enforcing the law r s. The investiga- 
tion of cases of occupational disease, or deaths from industrial diseases 
reported by hospitals or private physicians, often discloses the existence 
of places which are particularly hazardous. 

3. Periodic Medical Examination. — (a) Periodic medical examina- 
tion of minors as well as of adults, especially of those who enter upon 
forms of employment which are known to be hazardous or to predispose 
to disease, and continued supervision of the shops and factories which 
they enter, should be put into effect. 

(b) The physical examination of those who apply to public employ- 
ment bureaus for work is an effective way of instructing them as to the 
value of periodic medical examinations. 

(c) The examination of workers in factories is excellent for purposes 
of research. Such examinations should be conducted at regular and 
frequent intervals. They are most important in the development of 
preventive medicine, and their value should be urged upon workers 
so that their lives may be lengthened, and, that they may be protected 
against preventable disease. 

(d) The clinics maintained by health departments for the diagnosis 
and treatment of tuberculosis are far too narrow in scope. Tubercu- 
losis, while it may be regarded in frequent instances as an occupa- 
tional disease, is by no means the only vocational disease. If, therefore, 
tuberculosis clinics were made general diagnostic stations for those 



606 INDUSTRIAL HYGIENE 

who cannot afford to pay for periodic medical examination, not only 
would many otherwise undiscovered cases of tuberculosis be diagnosed 
in their incipiency, but various preventable diseases would be dis- 
covered before they had made headway. 

4. Educational Measures. — One of the chief efforts of public health 
officials in connection with any industrial hygienic campaign, must be 
directed to the education of employers and workers alike. Noon-hour 
talks to workers in factories, lectures before trade organizations of 
employers and employees, instruction of pupils in vocational schools, 
the preparation and distribution of placards and printed matter in 
various languages, are some of the methods through which educational 
work must be undertaken. 

Finally, if it is impossible to convince managers of industry that vast 
profits result from the adequate protection of workers, and if repeated 
attempts at education and persuasion fail, public health officials should 
engage in a campaign of education of the people generally, so as to 
create a public sentiment in favor of the enactment of legislation which 
will achieve the desired results. 

5. It would be desirable also to compel every factory and shop to 
keep a record in a book, especially designed for the purpose, of all cases 
of illness among employes. This record should state the cause, the 
nature of the illness, its duration and its consequences. Only by such 
a system can public health officials, employers, and employees intelli- 
gently ascertain against which points to direct their attack. In the 
program here outlined there are comprised several items, each of which 
is important enough to constitute a special field sufficient to engross 
the attention of those devoted to their study. Important as are the 
supervision of work-places by properly constituted authorities, the 
enforced reporting of occupational diseases and the formulation of 
standards of construction and management, so as to remove dangerous 
dusts and other products incident to trade processes, the periodic 
examination of workers and the proper education of all groups involved 
are nevertheless of still greater importance. 

Education, in so far as occupational diseases are concerned, has 
practically been neglected. A few schools, however, are making 
pioneer efforts in this direction. Emphasis upon the education of 
apprentices and of those attending trade and technical schools is greatly 
needed. If those who are about to enter industry or who are training 
in preparation for the assumption of supervisory functions in industry, 
were to receive adequate instruction as to the sources of danger to the 
health of workers and as to methods of prevention, a great forward step 
would have been taken. However, the best health laws and the best 
system of sanitary organization in industry, must prove worthless if 
the workers themselves are not taught to cooperate in the prevention 
of disease and the avoidance of preventable accidents. 

The managers of industry are also greatly in need of education, 
because, generally speaking, they are responsible for the initiation of 
protective measures to safeguard the health and lives of workers. The 



SCOPE OF INDUSTRIAL HYGIENE 607 

working people, as a rule, are utterly helpless in inaugurating any 
substantial improvement in the sanitary conditions of workshops 
except where trade unions are powerfully organized and intelligently 
directed. 

Statistical Data. — Statistical evidence has been furnished in abun- 
dance by a number of American writers, particularly by actuaries, and 
also by a great number of European writers, to prove conclusively that 
occupation, per se, is responsible for a relatively large number of deaths 
from tuberculosis among certain trade groups. The mortality from 
tuberculosis in all countries has repeatedly been shown to be greatest 
among those groups who were exposed to dust, inadequate ventilation 
or overcrowding. Bartenders, who certainly do not come in contact 
with any dangerous dust, as well as clerks and stenographers, seem to be 
an exception to this rule, as judged by Hoffman's comparative table. 
In the case of bartenders, however, other influences are found at work 
to undermine the powers of resistance, namely, long hours of work in 
what is frequently an ill-ventilated place, and sometimes alcoholic 
indulgence as well, which produce their serious effects and predispose 
to tuberculosis. Clerks and stenographers, as shown by Guilfoy and 
Wynne, in addition to many others, rank extremely high as to mortality 
from pulmonary tuberculosis. As a rule, however, the largest incidence 
of tuberculosis is encountered in those trades in which dust is generated 
in considerable degree in the course of work, and, generally speaking, 
the sharper, harder, and more insoluble the type of dust which is pro- 
duced in any industry, the greater is the mortality-rate from pulmonary 
tuberculosis, unless excellent devices for removing such dust are 
employed. 

The following table taken from a study by Dr. Frederick L. Hoffman 
illustrates the comparative mortality from pulmonary tuberculosis in 
certain occupations: 

PROPORTIONATE MORTALITY FROM TUBERCULOSIS OF THE LUNGS 1907- 
1910 OF OCCUPIED MALES IN CERTAIN OCCUPATIONS BY SPECIFIED 
AGE PERIODS. 

15 years and under, 15 to 24 years, 25 to 55 years, 
All occupied males. per cent. per cent. per cent. 

Farmers 9.9 26.9 32.1 

Tailors 13.2 52.0 47.5 

Carpenters 15.6 32.0 38.4 

Masons . 17.5 31.1 39.0 

Bakers 19.2 24.1 37.2 

Iron and steel workers .... 19.3 27.9 29.7 

Painters 23.3 34.7 39.2 

Cigar makers 26.3 54.8 45.0 

Machinists ...'.... 27.0 39.3 40.0 

Textile workers 27.3 38.6 45.5 

Bartenders 30.7 34.1 35.7 

Plumbers 32.6 32.8 41.7 

Glass workers 32.9 38.5 48.1 

Stone workers 33.5 33.3 47.8 

Clerks 35.5 42.4 44.8 

Printers 37.7 48.4 48.6 



608 INDUSTRIAL HYGIENE 

In what follows the subject will be treated in two main divisions: 

(1) A description of the more important occupational diseases, and 

(2) a presentation of practical considerations relating to environmental 
conditions from the standpoint of industrial hygiene, more particularly 
with respect to such subjects as lighting, ventilation, heating and others 
of like character, which medical officers should know in connection 
with their industrial hygienic supervision and inspection of shops, 
factories, and mercantile establishments, and which, though they may 
seem obvious have been found of practical importance. 

CLASSIFICATION OF THE CAUSES OF OCCUPATIONAL DISEASES. 

The following is a standard classification of the causes of occupa- 
tional diseases : 

1. Metallic poisons. 

2. Poisonous gases, vapors, fumes. 

3. Poisonous chemicals, liquid and solid (acids, alkalies, dyes, petro- 
leum products, etc.). 

4. Irritating or poisonous dusts (presented in the order of their 
harmfulness) : 

(a) Metallic dust. 
(6) Mineral dust. 

(c) Mixed dust. 

(d) Animal dust. 

(e) Vegetable dust. 

5. Infectious materials. 

6. Environmental conditions : 

(a) Vitiated air (odors, etc.). 
(6) Excessive humidity. 

(c) Excessive heat and cold. 

(d) Defective lighting. 

(e) Abnormal atmospheric pressure. 
(/) Fatigue, strains, inactivity and posture. 
(g) Dangerous machinery and miscellaneous accidents. 

OCCUPATIONAL DISEASES. 

In studying occupational diseases it should be kept in mind at the 
outset that a worker in a given industry, while particularly exposed to 
one or two metallic, chemical, or gaseous poisons, is often at the same 
time exposed to a number of other conditions or types of poisons which 
may be more largely responsible for the development of abnormal 
clinical conditions than the more obvious and conspicuous industrial 
poisons. For instance, a worker in a brass foundry is, above all things 
else, exposed to the development of spelter chills or brass ague, and 
while one should be particularly on the watch for these conditions, it 
should at the same time be borne in mind that a number of other agents 
of subordinate importance, it is true, may produce pathological con- 
ditions. Some of these agents are the following: Lead, which is 



OCCUPATIONAL DISEASES (309 

employed in some alloys of brass in considerable quantities; arsenic, 
which frequently contaminates the copper or the zinc which are con- 
stituents of brass, or arseniureted hydrogen, which may be evolved 
from the contact of metals with concentrated mineral acids which 
have not been freed from contamination with arsenic. Excessive heat 
may produce serious effects, and, finally, the oil which is used in con- 
nection with certain furnaces in brass foundries may produce odors 
which cause anorexia or digestive disturbances. In addition, the 
indescribable noise which is produced in certain foundries by a certain 
type of furnace may possibly have some influence in the production of 
certain nervous manifestations. In some instances, though not fre- 
quently, phosphorus is added to the metals which are used to make 
brass or brass alloys. Under certain conditions a large amount of 
carbon monoxide may also be present in brass foundries and cause no 
small amount of injury. In other words, in order to properly evaluate 
the possible causes of disease in brass-workers one must know some- 
thing more of trade processes and trade conditions than the mere sus- 
ceptibility to brass chills. Industrial hygiene studies should furnish a 
knowledge of these to the clinician. 

The therapy of most of the occupational diseases is to only a small 
degree medicinal. Sanitary engineering is preeminently the prophy- 
lactic agent in preventing occupational diseases. The industrial 
physician must have a fairly comprehensive knowledge of the principles 
of sanitary engineering to qualify properly as the health guardian of 
workers. 

Anilin Poisoning. — Uses of Anilin. — Anilin is a colorless oil which 
enters into the manufacture of a great variety of chemicals, which are 
used especially as dyes and as coloring substances in hair-dyes, as well as 
for fabrics, and in a multitude of objects made for commercial purposes. 
It is also used in the manufacture of photographic materials. It has 
now gained particular prominence in the manufacture of certain 
explosives. In whatever combination it is found, whether as phenylene, 
tolylene, diamine, or any other compound, it exercises the same general 
effects. Poisoning may result from the inhalation of its fumes, from 
having it spattered on the clothes and absorbed through the skin or 
from being swallowed with food. 

Symptoms. — It produces either an acute or chronic poisoning. In 
mild cases it causes a general weakness, unsteadiness and dizziness, 
a slight amount of general blueness of the skin and mucous membranes, 
with slow movements and a change in manner and speech very much 
resembling that of a drunkard. In more severe cases the blueness is 
particularly accentuated, and the patient shows difficulty in breathing, 
vomiting, bloody urine, and all the evidences of shock and collapse 
may appear, and the patient may die in coma. Methemoglobin is 
rarely found on spectroscopic examination of the blood. In chronic 
cases, in which there is a slow poisoning, there are usually present diges- 
tive disturbances, loss of appetite, eruptions of papules or pustules on 
the body (local irritant action), general weakness, headache, dizziness, 
39 



G10 INDUSTRIAL HYGIENE 

insomnia and fairly marked anemia. The symptoms may develop 
very rapidly in susceptible persons even when there has been a very 
limited contact with the poison, as in the case of a man who, when seen 
by the writer, had been engaged for but a few hours in filling bottles 
with a special writing fluid that contained anilin. He had allowed his 
hands to come in contact with the writing fluid while handling the 
hose through which these bottles were filled. At the end of one day he 
had marked symptoms of weakness, dizziness, vomiting, headache, 
intense blueness, with a short period of unconsciousness. 

Treatment. — The treatment is immediate removal to a cool spot, 
change of clothing, the administration of oxygen or artificial respira- 
tion, venesection, saline infusion and stimulation. 

The cleaning of retorts and stills, as in all other chemicals in which 
fumes are generated, is a potent source of danger. Frequently, carpen- 
ters and plumbers and other outside employees who are called in to do a 
casual job in a chemical factory are the ones most likely to be overcome. 
Prevention consists in the elimination of fumes, working with closed 
retorts and containers, preventing all spattering or soiling of clothes 
and parts of the body, and by wearing wooden-soled shoes, where 
anilin oil is likely to accumulate on the floor. Frequent blood exami- 
nations should be made and those showing a reduction in hemoglobin 
should be removed from contact with anilin. There are a variety 
of anilin dyes which in addition to the characteristic symptoms of 
anilin, or even without the presence of such symptoms, may cause 
different forms of skin lesions. 

Antimony. — Uses. — In connection with antimony, it is well to bear 
in mind that aside from its use in the manufacture of steelware and other 
metallic compounds, and in the making of vulcanized rubber, it is pre- 
sent also in varying degree in type metal. Its symptoms in printers, 
therefore, must not be overlooked, even though lead is by all means 
the most important of the poisons to which they are subject. It may 
cause skin irritation, digestive disorders, weakness, vertigo and feeble 
heart action, as well as albuminuria. In chronic cases it causes mental 
depression, irritability, headache, dizziness and general weakness. 

Arsenic Poisoning. — Uses. — Arsenic, although frequently mentioned 
as a source of poisoning when used in the coloring of wall-papers, is no 
longer of interest from that standpoint, because anilin colors have 
replaced it for this purpose. It does, however, figure in many occupa- 
tions where its presence is little suspected. It is a poison in the form 
of dust (arsenious acid, Paris green, or Scheele's green). It is employed 
as a parasiticide sheep-dip, for which purpose large vats are filled with 
a solution containing white arsenic, caustic soda or potash and flowers 
of sulphur. In the roasting of ores that contain arsenic its presence 
is a source of danger. It is employed in the manufacture of arsenic 
colors and dyestuffs and in artificial flowers. It is also used in taxi- 
dermy, and it must be remembered that it is found in connection with 
a variety of metals and mineral acids. Arsenic is present in many 
metals and also in concentrated mineral acids which have not been 



OCCUPATIONAL DISEASES 611 

de-arsenicated ; when, therefore, metals and mineral acids come in 
contact arsenic may be liberated as arseniureted hydrogen whose fumes 
are highly poisonous. 

Symptoms. — When the salts of arsenic come in contact with the skin 
of workers, especially with those who are susceptible, it causes an 
acneiform or eczematous eruption, and later forms ulcerations, especially 
where marked perspiration is present. It produces a peculiar pigmen- 
tation or bronzing of the skin, especially where the skin is moist. 
It also exercises an iniurious effect upon mucous membranes, causing 
conjunctivitis, edema of the lids, coryza, dryness and soieness of the 
throat, and particularly hoarseness. When ingested it has a special 
tendency to produce gastric symptoms, and in severe cases persistent 
vomiting, griping and purging. It may produce simple neuritis, 
although this is not frequently seen. Disturbances of sensation are 
far more frequently encountered, namely, paresthesia and anesthesia. 
It is likely to cause a perforation of the nasal septum, which does not, 
however, affect the anterior or lower margins of the cartilage nor the 
bones to which the cartilage is attached, differing in this respect from 
syphilis. At times arsenic has contaminated the sugars that are used 
in the place of malt in the manufacture of beer. 

As fumes of arseniureted hydrogen, arsenic is particularly dangerous. 
It is to be found in connection with processes of soldering, etching and 
everywhere in industry where metals and mineral acids are brought in 
contact, for both metals and mineral acids are frequently contaminated 
with arsenic. It is liberated in the cleaning of stills, in the process of 
galvanizing and enameling metal ware. 

Symptoms of Arsenic Fumes. — It produces nausea, malaise, headache 
and very soon marked vomiting. It also causes jaundice of a copper 
color, which is due to its destructive effect upon the red blood cells, 
and, as the result, hematuria is often encountered. Besides, it also 
causes suppression of urine and bladder irritation. It is essentially a 
hemolytic agent. Although excreted by the urine it is also found in 
the hair after it has been absorbed through the stomach. The exami- 
nation of the hair offers a particularly reliable method of diagnosis in 
medicolegal cases. 

Treatment. — The treatment of this form of poisoning is essentially 
through the administration of oxygen for a long period of time and by 
saline infusions. 

Benzine Poisoning. — Uses. — Benzine is an impure product which is 
used in the removal of grease and fat, in the cleaning of clothing (dry- 
cleaning), in India-rubber manufacture, and in waterproofing. 

Symptoms. — In acute cases, aside from its irritating effect upon the 
respiratory system and upon the eyes and skin, it causes nausea and 
vomiting, and when one is exposed to large quantities of the fumes it 
may cause drowsiness, weakness of the heart, cyanosis and uncon- 
sciousness. When its effects are not quite as profound, it causes marked 
headache and tremors. In chronic cases it causes headache, tinnitus, 
hallucinations and general symptoms of " drunkenness," 



012 INDUSTRIAL HYGIENE 

Treatment. — The only form of treatment is removal of the patient 
to the fresh air and the application of stimulants. 

Benzene or Benzol Poisoning. — Uses. — Benzol is the pure form of 
benzine. It is being used to an increasing extent in a great variety of 
chemical processes. It is employed in the making of illuminating gas, 
in dissolving resins and fats, in dye works, in the manufacture of 
explosives and by painters as a varnish remover. 

Symptoms. — Like all coal-tar products it has a depressing effect 
upon the nervous system. In acute cases it causes symptoms very 
much like those of benzine poisoning and is an irritant to the respira- 
tory, gastric and renal organs. It produces weakness, vertigo, cerebral 
and general "drunkenness," and in severer cases, tremors, pallor, 
lividity and prostration, terminating at times in delirium, followed by 
unconsciousness and death. In chronic cases it may cause purpuric 
spots upon the skin or mucous membrane, or slight hemorrhages from 
mucous membrane of various parts of the body, and fatty degenera- 
tion of the heart, liver and kidneys. 

Treatment. — Cases of acute poisoning require fresh air and stimu- 
lants. In chronic cases the patient must be completely removed from 
contact with the substance. 

Brass Poisoning. — Brass consists essentially of copper and zinc; 
variable quantities of arsenic, phosphorus and lead occur in brass 
either as impurities or because of their purposeful addition. These 
impurities must not be forgotten in studying brass-workers. The 
important fact to remember in connection with brass poisoning is 
that it is the zinc which constitutes the source of poisoning when it is 
volatilized. Zinc is almost exceptional among metals in that its 
boiling-point is below 1000° C. However, it begins to volatilize at a 
very much lower temperature than do many other metals, namely, at 
500° C. Fundamentally, then, one would be more correct in speaking 
of brass chills as zinc-poisoning. 

Uses. — Zinc is employed in making brass and bronze alloys, German 
silver and white metal; it is also used in the process of galvanizing and 
in the manufacture of rubber articles and paints. 

Symptoms. — It is generally believed that the fumes of zinc when 
inhaled, especially by susceptible persons, cause a superficial searing 
and consequent necrosis of epithelium and that the absorption of this 
necrotic proteid material gives rise to the malaria-like symptoms of 
zinc poisoning, namely, chills, fever, sweating and occasional tempera- 
ture. 

The first effect of the inhalation of zinc fumes is dryness and soreness 
of the nose and throat, a sense of tightness in the chest, a feeling of 
lassitude, loss of appetite and a slight cough. These symptoms are 
encountered more frequently in the winter time, and the chill is first 
felt when the worker leaves his place of business and comes in contact 
with the cold, outer air. The chill lasts for a variable period of time 
and is followed by a feeling of great warmth, during which the tempera- 
ture is frequently elevated and a profuse perspiration appears. The 



i 



OCCUPATIONAL DISEASES 613 

entire attack is so well recognized by the worker, and so short in dura- 
tion, that physicians are rarely called to treat the case. The workers 
who have suffered a chill feel somewhat weak the next morning, but 
generally are able to go to work. New men are particularly subject 
to these attacks, and what immunity is acquired is of brief duration, 
so that at the end of a brief holiday those who have acquired immunity 
are once again subject to spelter chills. These attacks are most 
frequent during the winter season, when the windows are closed, and 
the fumes which result from pouring the metal are not carried off by 
adequate ventilating devices. 

Treatment. — Treatment of this condition, as understood by all 
experienced brass-workers, is the application of warmth, the use of 
drinks, especially milk, and saline purges. Preventive treatment is 
free ventilation, the removal of fumes caused by the pouring of brass 
through exhaust devices, and the liberal use of hot milk before and after 
the pouring process. 

Carbon Bisulphide Poisoning. — Carbon bisulphide is derived from 
coal-tar products and is obtained from the treatment of red-hot carbon 
with sulphur vapors. It has a chloroform-like odor and is highly 
volatile and colorless. 

Uses. — It dissolves all resins except shellac. It does not, however, 
dissolve vulcanized rubber. From it is derived carbon tetrachloride 
and sulphur monochloride, both of which are used to dissolve rubber. 
It is highly inflammable, and because of its great volatility is used to 
produce a lowering of temperature in various trade processes. It is 
applied to the extraction of aromatic oils; it is also used as a disinfectant 
and for removing grease, as well as to remove oil from seeds and other 
oily residues. 

It helps to combine the sulphur with rubber in the process of vulcan- 
ization, making the rubber more elastic and durable. 

Persons employing it are particularly susceptible in hot weather, and, 
as in the case of all dangerous fumes, its effects are most marked when 
ventilation is not of the best. In general it resembles chloroform in 
its toxic effects. 

Symptoms. — It has a special tendency to produce atrophy and fatty 
degeneration of muscles and connective tissue and is hemolytic. In 
acute cases, it causes severe headache, pains which radiate from the 
head downward, dizziness, pallor, a feeling of faintness, nausea and 
vomiting, marked drowsiness, impulsiveness and unsteady gait. It 
may cause hallucinations, and death may occur following uncon- 
sciousness, coma or convulsions. In chronic cases the condition of 
general weakness and depression, which it tends to cause, is preceded 
by a period of excitement and general exaltation. Its effects cause it 
to resemble a case of delirium tremens in many respects, for there 
follow, after the lapse of a short time, faintness, headache, weakness, 
depression, insomnia, nightmares and hysterical manifestations; the 
digestive system is also very much disordered. Still later, there usually 
follow general emaciation, tremors, localized paralysis, constipation 



614 INDUSTRIAL HYGIENE 

and anemia, and the case may resemble in some respects one of loco- 
motor ataxia. Mental disturbances are extremely marked. The 
prognosis is had in these chronic eases, although the patient may 
remain alive a relatively long time. 

Treatment. — The important feature in the prevention of this poison 
is extraction of fumes from the workroom and also the prevention of 
the soiling of the hands and other parts of the body with this agent. 
There are no specific remedial measures for this form of poisoning. 

Carbon Dioxide Poisoning. — Carbon dioxide is generated in varying 
degrees in places which are close and confined, or lacking in ventilation, 
especially in the presence of large numbers of persons, and by gas flames 
or lamps. It is also generated in various processes of decomposition, 
in distillation, and in tanning. Generally speaking, its presence even 
in fairly large quantities produces little or no effect . It is chiefly of 
importance as an index of air contamination. 

Symptoms. — It may produce headache, dizziness, a feeling of weak- 
ness, difficult breathing and may, as in the case of those cited in the 
classical description of the " Black Hole of Calcutta," cause delirium 
and finally terminate in unconsciousness and death by suffocation. 
In the holds of vessels where fermentable material such as grain or 
molasses are carried it has been known to be generated in such quanti- 
ties as to be the cause of fatal poisoning. 

Treatment. — Fresh air, administration of oxygen and stimulants are 
required in the treatment of cases of carbon dioxide poisoning. 

Carbon Monoxide Poisoning. — While a great deal has been written 
about the variety of poisons which produce effects that are almost 
dramatic in their clinical manifestations, not nearly enough has been 
said to impress upon medical men and upon factory managers and 
workers the widespread prevalence of varying degrees of carbon 
monoxide poisoning. There are a multitude of industrial processes 
in which these fumes are generated and may produce chronic illness. 
It is desirable to give special emphasis, however, to the multiplied 
instances of exposure to small quantities of carbon monoxide which 
produce mild forms of carbon monoxide poisoning. Carbon monoxide 
is found wherever furnaces, gas irons, gas-heating devices and improp- 
erly maintained heating arrangements exist; also in garages, laundries, 
various drying chambers and stoves, especially where coke is used, and 
also where the salamander is employed. 

Symptoms. — The susceptibility to carbon monoxide varies greatly. 
Some are so readily susceptible that they may succumb to its fumes 
as if they were knocked down by a sudden blow, showing no prodromal 
symptoms. Usually, however, the patient feels a throbbing in the head, 
ringing in the ears, gastric distress, nausea or vomiting, weakness in the 
legs, general faintness, severe headache, dimmed vision and at times 
suffers from hallucinations. The patient feels knocked out and helpless. 
Convulsions and coma may rapidly follow. Apfelbach calls particular 
attention to the fact that carbon monoxide cases in coma, contrary to 
usual teaching, do not always have rosy cheeks and bright red lips, but 



OCCUPATIONAL DISEASES 6l5 

that frequently they show cyanosis and pallor. The former condition 
is usually found in coma resulting from illuminating and coal-gas 
poisoning rather than from other sources of carbon monoxide. Fever 
usually supervenes in cases of coma, the respiration is deep and labored, 
the blood-pressure at first rises, and subsequently, both respiration and 
pulse become rapid and feeble. It is generally taught that the spectro- 
scope will show the presence of carboxyhemoglobin. The experience 
of a number of clinicians who have employed the spectroscopic test, 
does not, however, bear out this teaching. There must be a con- 
siderable degree of saturation of the blood to give this spectroscopic 
finding. The symptoms of acute carbon monoxide poisoning are very 
frequently not severe and may consist merely in epigastric distress, a 
feeling of great weakness, especially in the legs, throbbing in the temples 
and headache. Pneumonia is a very frequent form of termination in 
cases of gas poisoning. Various forms of mental disturbance have 
also followed acute attacks of gas poisoning. Local or extensive 
paralyses may ensue, although this is very infrequent. 

Treatment. — In acute gas poisoning, artificial respiration or the use 
of the pulmotor and oxygen are of the first importance. The patient 
should be kept warm and stimulated. 

Chronic Carbon Monoxide Poisoning. — Cases of chronic carbon 
monoxide poisoning are the ones which are the least readily diagnosed 
and which are probably the most numerous in every industrial com- 
munity. 

Symptoms. — In this form of poisoning patients complain very fre- 
quently of headache, dizziness, nausea, vomiting, lack of appetite, 
weakness, impairment of memory, nervousness, and usually show fairly 
marked anemia. The symptoms in some cases are extremely few and 
mild, headache being the only one complained of. There are, however, 
a group of persons who seem to have a natural tolerance for carbon 
monoxide and w r ho do not show any symptoms, although exposed for 
prolonged periods to its fumes. Irritability and so-called neurasthenia 
as well as disturbances of appetite and digestion, are encountered very 
prominently among those who are not tolerant. Apfelbach calls 
attention to the blood changes in chronic carbon monoxide poisoning. 
He found a tendency to polycythemia and a high hemoglobin content 
which he thinks are of diagnostic importance. 

Treatment. — The treatment for these cases of chronic carbon 
monoxide poisoning is obviously the removal from an environment 
in which they are subjected to further poisoning, an abundance of fresh 
air and general tonic treatment. 

Compressed-air Illness, Known as Caisson Disease — "Bends"; 
"Chokes". — This disease is frequent among those who work under 
compressed-air and who emerge rapidly from such an environment into 
a normal one. In the construction of the East River tunnels in New 
York City, Dr. Seward Erdman and Dr. Keys reported 3692 cases 
among 10,000 men who were employed in this work. In this tabula- 
tion they excluded all slight cases, and Erdman believes that hardly 



616 INDUSTRIAL HYGIENE 

10 per cent, of all the men employed escaped from the "bends." The 
accepted theory of the production of this condition is that it is due to 
the sudden escape of bubbles of gas from the supersaturated blood 
into the surrounding tissues, upon which these bubbles have a destruc- 
tive or tearing effect. The blood and all the soft tissues of those who 
enter a compressed-air chamber become supersaturated with nitrogen, 
which, if the pressure is slowly reduced, flows off from the tissues by 
means of the circulating blood into the pulmonary alveoli and is 
expired. When the surrounding air-pressure is suddenly reduced the 
nitrogen tends to escape in bubbles from the tissue and blood before 
it can reach the alveoli, thereby working destruction upon the nerves 
and muscular tissue in varying degree, some of these larger air bubbles 
producing compression symptoms upon the peripheral nerves of the 
central nervous system. This is the generally accepted theory. The 
greater the amount of pressure the more numerous the cases. 

Symptoms. — The symptoms seem to begin when an air pressure 
of +20 pounds is reached. The New York State laws and other laws 
have been so framed that the amount of time to be spent by each 
working man in a compression chamber before entering upon his 
work, and in the decompression chamber after leaving work, are 
exactly specified for varying degrees of air-pressure. These laws 
also specify the length of time the worker may continue under the 
various pressures maintained in tunnels and other compressed-air 
chambers. 

Prevention. — The most important preventive measure is a curtail- 
ment of the amount of time spent by the worker under these abnormal 
atmospheric conditions. When we reach a pressure of +50 pounds, 
which is near the maximum permitted, and when for short periods the 
men are required to work under a pressure of +60 pounds, the working 
period must be reduced to as little as one-half hour if serious results 
are to be averted. 

Workers who suffer from malnutrition or lowered resistance from 
any cause, as well as those who are alcoholic and who are easily fatigued, 
are particularly susceptible. Organic diseases of the heart, blood- 
vessels and lungs are also predisposing causes. After the age of thirty 
years there is a progressively increasing inability to endure such expo- 
sure. Fatigue is a particularly predisposing factor; fat men are bad 
risks for work under high pressure. 

Sensations under Compression. — The sensations are most varied. 
Those who work under an increased air-pressure may be entirely 
free from symptoms, and while there is no absolute immunity, they 
may experience none of the sensations that are usually described, 
namely, the pressure upon the ear-drums and the pain and discomfort 
which it occasions, resulting at times even in the rupture of the drum- 
membrane. Under compressed air the voice is changed in character 
and whispering is impossible. The symptoms of caisson disease are 
never experienced until a workman emerges from compressed air, and 
they are the result, always and only, of too rapid or insufficient decom- 



OCCUPATIONAL DISEASES 617 

pression. After a variable period, and sometimes quite suddenly, 
excruciating pains may be felt in various muscles of the legs or in the 
abdomen, and a workman will fall helpless to the ground. Abdominal 
pains are the most frequent of all symptoms; other symptoms depend 
entirely upon the site of the lesion caused by the bubbles escaping 
from tissues or the point at which they produce compression. The 
nervous system is particularly affected. There may be eye or ear 
symptoms or peripheral nerve pains, or disturbances in sensation of a 
most varied character. A cerebral gas embolus may produce a great 
variety of symptoms, depending upon the area of the brain which is 
attacked. Spinal cord lesions produce the effect of a transverse 
myelitis or they may produce effects of a localized character. As 
the result of vascular damage a mottling or spotting of the skin 
may be seen. Sudden collapse and death are usually due to gas 
embolus. When the pulmonary vessels are attacked a severe form of 
dyspnea, called "chokes," is caused. Extensive emphysema of soft 
tissues may follow. There may be nausea and vomiting. Permanent 
serious injury or death rarely occurs in those cases which have pains 
limited to the extremities. These cases are spoken of as " bends." 
In the milder cases the patients are generally well in a few days. 
Erdman reports a total of only 1 per cent, of fatalities and permanent 
injuries among the 3692 cases which came under his notice. 

Prevention. — A method of uniform decompression, which is the one 
most in use, consists in a continuous and uniform rate of reduction of 
pressure. There is a newer method of decompression which is known 
as "stage" decompression, in which the worker or patient passes from 
the place of maximum air-pressure to successive air locks which have 
a progressively lower air-pressure, so as to necessitate walking and 
exercise on the part of the patient, which aids decompression. This 
is an ideal method of decompression. 

When cases of caisson disease occur, no matter how serious the case, 
the patient should be returned immediately to a compression chamber, 
where he is recompressed. 

Treatment. — Some of the most severe cases of paralysis when 
promptly treated by recompression have responded within a few 
moments. Recompression must not be delayed. Exercise and mas- 
sage as well as inhalation of oxygen, and the use of stimulants and 
heat, are generally depended upon to assist in restoring patients. 

Lead Poisoning. — Lead poisoning is also spoken of as saturnism or 
plumbism. From an industrial standpoint it is the most widely preva- 
lent disease with which we have to deal. 

Uses of Lead. — The list of industries in which lead is employed is an 
extremely long one. It is used in many industries in combination with 
other substances, and its identity may be so masked as to make it 
almost unrecognizable, unless one is keenly on the alert to discover its 
presence. A great deal of caution must therefore be exercised by 
clinicians in ruling out lead as a cause of disease when they observe 
symptoms which suggest lead poisoning, even if the occupation of the 



618 INDUSTRIAL HYGIENE 

person at first sight seems unrelated to the use of lead. It has, for 
instance, been known that laces or cotton thread have been weighted 
with lead, and it is recorded by some that persons using such weighted 
thread in sewing have been affected through biting off such threads 
between their- teeth. 

In the mining of lead and in the manufacture of both red and white 
lead there is a quite obvious source of danger which is easily recognized. 
In the metal industries lead is frequently employed. It is also met with 
in type-setting, printing, metal refining, jewelry work, painting, in the 
glazing of china and earthenware, in the manufacture of linoleum, of 
electric batteries, glass-cutting, in the manufacture of dyes and var- 
nishes and in many other industries. 

Lead poisoning in itself is of serious import, not only because of its 
toxic action, but because it lowers general resistance and predisposes 
to tuberculosis. In fact printers, and, in the experience of the writer, 
painters as well, are notoriously subject to tuberculosis. It is not 
readily absorbed through the skin, though occasionally one meets with 
cases of lead poisoning which have resulted from the use of cosmetics 
and hair dyes containing lead. Lead is not infrequently absorbed 
through the mucous membrane of the respiratory tract, but, as a rule, 
it is swallowed in the form of metallic dust and absorbed through the 
mucosa. 

It has been debated whether the inhalation of lead fumes in compos- 
ing rooms where lead is melted in considerable quantity is a possible 
source of lead poisoning. While it is difficult to demonstrate the 
presence of lead in the air in such rooms, it has, however, been definitely 
shown that in the process of melting, fumes of lead are given off at a 
temperature very considerably below the boiling-point of lead, and it is 
because numbers of cases of lead poisoning have been traced to this 
source, that regulations have been enacted by various communities 
compelling the installation of mechanical devices to exhaust fumes 
arising from lead melting pots. 

When lead is swallowed and enters the stomach it is converted into 
lead chloride by the hydrochloric acid of the gastric juice, and in this 
form it is soluble and capable of absorption. Attention is frequently 
called to the fact that lead is converted into an insoluble compound by 
combination with proteids, and on this account unwarranted reliance 
has been placed upon the capacity of ingested proteids, especially 
milk, to neutralize the poisonous effects of lead by combining with it. 
Lead carbonate is more readily soluble than lead sulphate, but both 
are practically equally capable of causing serious lead poisonings. 

The susceptibility to lead poisoning varies greatly in different indi- 
viduals, females being particularly susceptible. On the other hand 
one encounters numbers of men who can handle lead with impunity for 
considerable periods of time and apparently escape its ill effects, 
while others are exposed to it but a very brief period and develop 
severe manifestations of plumbism. 






OCCUPATIONAL DISEASES 619 

Symptoms. Anemia is usually the first and one of the most pro- 
nounced manifestations of lead poisoning and may progress to such a 
degree as to become quite grave. Oliver reports that from 30 to 70 
per cent, of the cases of anemia studied by him showed an abnormal 
condition of the red blood cells. This change in" the red blood cells is 
a granular degeneration which is evidenced under the microscope by 
numerous dark, punctate granules which give the red blood cell the 
appearance of being stippled. These cells are known as basophiles. 
The stain most useful for demonstrating these basophiles is one com- 
posed of 2 grams of methylene blue, 12 grams of sodium bicarbonate 
and 200 grams of distilled water. The specimen which is to be exam- 
ined is first placed in absolute alcohol, or a mixture of alcohol and ether, 
for half an hour; then dried and stained for one minute with the 
solution just described. The specimen is then washed away with the 
distilled water until the color is almost faded. The writer in studying 
more than 420 painters in connection with the industrial hygienic 
work of the Department of Health of the City of New York, found 
basophilia present in only 14 per cent, of 122 painters who gave 
definite evidence of lead poisoning. Although Ehrlich, Grawitz and 
others speak of basophilia as being diagnostic, Teleky, Biondi and 
others place very little reliance on this diagnostic sign. The experience 
cited by the writer would tend to confirm the opinion of the latter that 
this sign is not of important diagnostic value in lead poisoning. 

The lead line on the gums is held to be a very important symptom 
of lead poisoning by most investigators. The experience of the writer 
is in accord with that of a number of observers who contend that the 
lead line is not found in the majority of cases which give evidence of 
lead poisoning. This lead line, which is a fine blue line seen at the 
margin of the gums close to the teeth, is found especially in persons 
who have neglected the care of their teeth. However, it is occasion- 
ally found in persons who have kept their teeth clean. The lead line 
must be differentiated from a soft sediment of lead sulphide which at 
times appears on the surface of the gums of persons employed in lead 
industries and which can be easily rubbed or washed away. 

Colic and constipation are encountered early in lead poisoning and 
are important symptoms. The abdominal pain is usually of a very 
severe character and is accompanied, as a rule, by very marked con- 
stipation. Occasionally one meets with cases in which lead is found in 
large quantities in the urine and in which other evidence of lead 
poisoning is present, but in which constipation or colic, or even both, 
may be absent. Lead colic has frequently been mistaken by surgeons 
for appendicitis, and they have not infrequently operated on the 
basis of a mistaken diagnosis. Recently a case of lead poisoning was 
reported to the writer. As the result of an investigation three other 
cases were discovered in fellow employees. One of these three was 
suffering from excruciating abdominal pain which led to a diagnosis 
of appendicitis, and resulted in an operation which disclosed a normal 
appendix, the abdominal pain continuing after the operation without 



620 INDUSTRIAL HYGIENE 

mitigation. I laving- in mind the industrial background in this par- 
ticular instance, the diagnosis of lead poisoning was suggested and 
proper treatment overcame this severe abdominal colic. One of this 
group of three, was a girl who developed sudden maniacal manifesta- 
tions and who had convulsions. Her case was diagnosed as one of 
hysteria. The investigator informed the hospital attendants of the 
probable causative agent and suggested lead poisoning. Subsequent 
developments confirmed the fact that this was a case of lead enceph- 
alopathy. 

Headache, though not present in all instances, is a very frequent 
symptom and is usually of severe character. 

As already cited, convulsions, delirium, and other marked nervous 
symptoms may result from plumbism. 

The nervous system, both central and peripheral, seems to be par- 
ticularly susceptible to the effects of lead-poisoning, and various forms 
of paralyses, of which "wrist-drop" is the most familiar, are found in 
this disease. 

Miscellaneous Symptoms. — Albuminuria is often found not only 
in connection with the attacks of lead colic but as a permanent patho- 
logical condition. 

Increased blood-pressure and hardening of the arteries is a frequent 
result of lead poisoning. The studies of the writer would seem to 
indicate that workers exposed to lead poisoning for a number of years 
may show a blood-pressure considerably below normal. This depres- 
sion, it seems, precedes the characteristic rise in blood-pressure which 
later develops. 

So-called rheumatic pains are very frequently complained of and may 
be of diagnostic value in association with anemia, colic, constipation, 
headache and other signs. 

The Wassermann reaction in persons suffering from lead poisoning 
was studied by the writer in 124 cases, and in no instance did it seem 
that lead poisoning, per se, produced a positive Wassermann reaction. 
Whenever this reaction was obtained it could be explained on clinical 
evidence or a history of syphilis. 

The writer has found the following classification of cases of lead 
poisoning not only of value for purposes of statistical study but from 
a therapeutic standpoint as well. 

1 . The active cases in which there are definite clinical manifestations. 
The diagnosis in these may rest exclusively on distinctive objective and 
subjective signs, or these signs may be confirmed by the presence of 
lead in the urine. 

2. The second group are known as latent cases, in which lead is 
found in the urine occasionally in association with a lead line or with 
basophilia, but the patient is free from the usual subjective and objec- 
tive evidences of lead poisoning. In these cases a disturbance in 
metabolism or the administration of potassium iodide may dissolve 
the insoluble lead albuminate circulated in the blood or deposited in 
the various tissues and cause acute manifestations of lead poisoning. 



OCCUPATIONAL DISEASES 621 

The discovery of these latent cases is of great importance from the 
standpoint of prevention of active manifestations of lead poisoning. 

3. There are borderline cases in which some one or two suggestive 
symptoms would strongly indicate the necessity of keeping patients 
showing such symptoms under careful supervision. 

Although W. Gilman Thompson places little or no reliance upon 
the discovery of lead in the urine, in the experience of Oliver, as con- 
firmed by the studies of the writer, the discovery of lead in the urine 
is of the utmost diagnostic value. The following technic for the dis- 
covery of lead in urine elaborated by Durand, has given results far 
superior to the method more commonly in vogue and is of very great 
diagnostic value: 200 to 300 cm. of urine are treated with 5 cm. of 
bromine in a porcelain casserole and evaporated on a hot plate to about 
50 cm. The residual mass is then transferred to a platinum dish and 
evaporated nearly to dryness; 10 cm. of concentrated nitric acid are 
then added and the evaporation continued to dryness, the residue being 
again moistened with nitric acid and evaporated to dryness. The 
residue is then ignited to a low red heat to burn off carbonaceous 
matter. It is cooled, taken up with 4 or 5 cm. water and 2 or 3 gm. 
ammonium carbonate, evaporated to dryness and the flame played 
upon the dish until the ammonia is driven off. It is then taken up 
with 15 to 20 cm. of 10 per cent, acetic acid and boiled and filtered 
hot into a small test-tube. It is then cooled and 1 or 2 drops of colorless 
ammonium sulphide and a drop of 25 per cent, hydrochloric acid added 
and compared with standard samples, prepared by adding known 
amounts of a solution of lead acetate containing 1 gram of lead per 
1000 cm. Even less than 4^ mg. gave a distinct reaction. 

Prevention. — Women and children should not be allowed to work at 
any processes in which lead poisoning is likely to develop. The mixing 
of dry lead pigments should not be permitted to be carried on where 
any workers have congregated, without efficient mechanical devices 
for removing the lead dust generated. All poisonous agents containing 
lead should be labeled in the language best understood by workers, 
and such warning should be supplemented by verbal instruction, so 
that workers may be on guard to protect themselves while engaged in 
any process in which lead poisoning is a hazard. Personal hygiene 
is of the utmost importance. Workers should be forbidden under all 
circumstances to eat in rooms where lead dust may be present. Hot 
water should be supplied and likewise soap and brushes, and their use 
should be enforced before each meal and before leaving work. In 
those trades where lead is employed, the face, and especially the mus- 
tache or beard, should be carefully washed before eating and before 
leaving work. Likewise the mouth should be thoroughly rinsed. Xo 
worker exposed to lead poisoning should begin work on an empty 
stomach. Milk taken before beginning work and also during the day 
has value as a protective agent. Alcohol should be avoided, as it 
seems to cause a special predisposition to lead poisoning. Smoking 
and chewing in places where lead dust exists should be forbidden. 



622 INDUSTRIAL HYGIENE 

Treatment. — The use of acid lemonade prepared with sulphuric acid 
or magnesium sulphate, which is so common in trades in which lead 
dust exists, gives a misleading sense of safety to the workers to whom it 
is furnished, and its benefits are doubtful. Oliver states that calcium 
sulphide, one grain every day, given in tablet form to workers exposed 
to lead-poisoning, has acted favorably as a preventative. 

For the colic, hot applications should be applied to the abdomen. 
Constipation, which is usually associated with colic, may be so marked 
that cathartics and purgatives may not be effective, and in such cases, 
small doses of croton oil must be resorted to. Lead colic, when very 
severe, may require the use of opiates. It is said that it can be relieved 
by the administration of sodium monosulphate given from one-half 
to one grain, three times daily. Dr. Stevens of Cardiff administers 
one-quarter-grain doses of calcium permanganate and claims to have 
beneficial effects. 

In administering potassium iodide to those suffering from lead 
poisoning, it is very important that small doses should be used at the 
beginning, otherwise too large quantities of lead may be suddenly 
dissolved and give overwhelming symptoms of poisoning. 

For paralysis due to lead, massage and electricity are generally 
employed, and are sometimes effective. Sir Thomas Oliver and Mr. 
T. M. Clague have reported favorable results from the double electrical 
bath in which the fore limbs are placed in one bath containing a positive 
electrode and the hind limbs in another containing a negative electrode. 
In animal experiments a few baths are said to have been effective in 
promptly removing paralysis. Oliver uses the bath not only as a 
curative measure in cases of lead poisoning, but believes that its 
employment once or twice a week is a preventive of lead poisoning. 
He is not borne out in this opinion to any considerable degree by other 
observers, and the subject is one for further experimentation. 

Mercury Poisoning.— Uses. — Mercury is used in the manufacture of 
felt hats, in the making of scientific instruments and various kinds of 
lamps, photographic mounting, and in the manufacture of explosives. 
It is no longer used in the making of mirrors, for which a solution of 
silver nitrate and Rochelle salt are now employed. 

Symptoms. — Susceptibility varies. The poisoning may be acute or 
chronic. In acute cases, diarrhea, severe abdominal pain, and in some 
cases vomiting and prostration are the chief symptoms. Suppression 
of the urine soon follows. The acute cases are usually encountered in 
corrosive sublimate poisoning and are rarely seen in industrial practice. 
In subacute and chronic cases, stomatitis, which involves a consider- 
able amount of inflammation of the mouth, accompanied with pain, is 
one of the most frequent symptoms. These patients suffer from saliva- 
tion, the gums become loose, swollen and red and bleed readily, and 
may discharge a certain amount of pus. The mouth has a foul odor. 
The involvement of the buccal mucous membrane distinguishes this 
form of stomatitis from the marked inflammatory condition of the 
gums seen in workers who are careless of oral hygiene. Loss of appe- 






OCCUPATIOXAL DISEASES 623 

tite is very frequently complained of by those exposed to mercury. 
Slight diarrhea is also at times encountered. Nervous irritability, 
while frequently spoken of, was apparently not common in the exper- 
ience of the writer who examined several hundred of those exposed to 
mercury. Tremors, both coarse and fine, involving the muscles of the 
face and the hands principally, and more frequently generalized, are 
the most prominent of the nervous symptoms and may become 
extremely severe. Sharp, sudden contractions of muscles have been 
reported. The tremor when it advances results in an inability to hold 
objects, and may even make locomotion very difficult. Among 
Belgians who have at times carried on felt-hat manufacture in the 
homes, exposing all members of the family to contact with the solution 
and fumes of nitrate of mercury, some extreme cases have been reported. 
Such severe cases are apparently not frequent among workers in this 
city; the great labor turnover may be in part responsible for the 
lighter forms of mercury-poisoning seen in this city. 

The frequency of nephritis from industrial mercury poisoning is 
apparently an unsettled question. 

Anemia and digestive disturbances are very common accompani- 
ments of mercury poisoning. 

Occasionally deep ulcers in the mucous membrane of the mouth or 
upon various parts of the body are found in cases which are suffering 
from this disease. 

Mercury poisoning lowers the resistance and predisposes to tubercu- 
losis and other diseases. 

Prevention and Treatment. — Prevention of mercury poisoning can 
be effected by the use of proper mechanical exhaust devices and by 
proper covering for the hands and other parts of the body coming in 
contact with solutions or salts of inercury. The use of sweat baths 
at frequent intervals seems effective. Potassium iodide is of value to 
those suffering from poisoning. Astringent solutions are of service 
in curing the stomatitis, which under such treatment lasts for a varying 
period of time. In those who have severe tremors for any length of 
time the removal of this symptom is virtually impossible. 

Poisons Encountered in Munition Works. — Nitrous Fumes. — In con- 
nection with the manufacture of explosives a large number of cases 
of fume poisoning have been reported. These are frequently unrecog- 
nized. These cases of "fume poisoning" result from the inhalation of 
fumes arising from nitric or mixed acids either in the ordinary course 
of work or when there is an accidental flowing over, the immediate 
cause of the condition being nitric peroxide. 

Pathology. — The effect seems to be due to the corrosive action of 
these fumes upon the mucous membranes, according to Tr. W. G. 
Hudson, who has had exceptional opportunity to study this condition. 
This corrosive action is particularly marked in those who breathe in 
deeply in the presence of such fumes and may result very rapidly, or 
after the lapse of a number of hours, in a marked edema of the lungs. 
When pulmonary edema does not set in immediately the condition 



624 INDUSTRIAL HYGIENE 

may give rise to a massive or lobar pneumonia whose severity depends 
upon other complicating conditions. 

Symptoms. — The fumes cause coughing, soreness in the upper 
respiratory tract and after several hours or several days weakness and 
dyspnea follow, being accompanied sometimes by very severe abdomi- 
nal cramps. The dyspnea is the most marked symptom and bloody 
sputum may be expectorated, the case terminating in pulmonary 
edema. This is a typical picture of acute nitrous fume poisoning. 
Unlike the fumes of ammonia and other sharply irritant gases nitrous 
fumes do not cause spasm of the glottis. The various forms of lobar 
pneumonia are apparently encountered when the fumes have penetrated 
into the terminal bronchi and alveoli. The outcome of the case 
depends upon the amount of lung tissue that has been affected by the 
corrosive action of the fumes. 

Preventive Measures. — Oxygen and air helmets and ammonium car- 
bonate sprays are in use either as preventive measures, or for the 
neutralization of the fumes, or support of the patient after he has been 
subjected to the fumes. Shallow breathing in the presence of fumes is 
of the utmost importance as a preventive. Workers are advised to 
breathe through respirators which are provided with a sponge moistened 
with a saturated solution of washing soda (sodium carbonate). The 
administration of 15 drops of chloroform thoroughly shaken up in half 
a glass of water taken at one time or in small sips over an hour is highly 
recommended by Hudson. It certainly seems to give relief from the 
effects of bronchial spasm and abdominal cramps. Hudson found that 
the combination of 15 drops of chloroform, 1 tablespoonful of aromatic 
spirit of ammonia and about f glass of water, thoroughly shaken, and 
taken in small portions in one-half to one hour, has an even better 
effect. The inhalation of this mixture seems to be of some value. The 
oil spray used with a powerful nebulizer working under sufficient air- 
pressure to reach the smaller bronchi has given excellent results. 
Liquid albolin containing a small amount of thymol and menthol is of 
value as a sprav. These recommendations are based on the reports 
of Dr. W. G. Hudson. 

Nitro-aromatic Poisons. — Hudson, ignoring a classification based 
strictly on chemical composition, includes under nitro-aromatic 
poisons, di-nitro-benzol, tri-nitro-benzol, mono-di- and tri-nitro-toluol 
and nitro-naphthaline. These poisons have come into great importance 
in the manufacture of the newer explosives. Of these, TNT, or tri- 
nitro-toluol, has received perhaps the most attention. The higher 
the nitration of these products, in other words the more N0 2 radicals 
they contains, the more dangerous they are to the workers, so that 
tri-nitro-toluol is very much more dangerous than mono-nitro-toluol, 
etc. As Hudson points out, while these are nitro-aromatic bodies, 
they do not behave like nitrites or nitrates but exert an effect peculiarly 
their own. 

Pathology. — The poisonous action of these agents is chiefly exerted 
upon the blood. They seem to produce a relative lymphocytosis, 



OCCUPATIONAL DISEASES 625 

with a considerable reduction in the number of polymorphonuclear 
leukocytes. The red cells undergo changes in size and form. They 
become granular, crenated and broken up. The chief change upon the 
blood is noted in a marked deepening of the patient's color. 

Symptoms. — In acute poisoning from these various nitro-aromatic 
compounds, there are present digestive disturbances which may merely 
amount to a distaste for food or pains in the abdominal area, which are 
usually accompanied by a fairly severe headache. Marked weakness 
together with dizziness and restlessness and a disinclination or inability 
to carry on work are the chief symptoms. These are soon followed 
by cyanosis with a certain amount of temperature, which is apparently 
due to the large amount of hematin which is set free in the blood by the 
destructive action of the poison. 

Chronic Poisoning. — The more usual form of poisoning is a slow, 
chronic intoxication which may also show itself in the form of slight 
digestive disturbances, nausea, or loss of appetite, a slight headache 
and weakness, and dizziness. The patient feels increasingly weak and 
unable to work and, as Hudson describes it, they speak of feeling 
"down and out." Jaundice which is usually slight at the beginning 
appears upon the skin, the patient also complains of constipation, and 
the urine becomes quite dark in color. A progressive asthenia develops. 
Unless the patient is early removed from contact with the poisonous 
agent, jaundice deepens, vomiting may become uncontrollable, and the 
patient dies of a condition which closely resembles acute yellow atrophy. 
After death, it is found that the blood, the liver, the kidneys and the 
heart have borne the brunt of the trouble. 

In the loading of shells in munition factories, the tri-nitro-toluol 
must be melted, and the fumes of a given dose of this as well as other 
nitro-aromatic bodies seem to be more poisonous than the same dose 
swallowed or absorbed through the skin. In hot weather, poisoning 
from the nitro-aromatic bodies is particularly frequent. They seem 
to act more powerfully in smaller doses because of their comparative 
insolubility in the stomach and their cumulative action upon the 
blood, heart, liver and kidneys. Dr. Hudson has been able to prevent 
many cases of nitro-aromatic poisoning by periodic examination of the 
blood of persons who are exposed. As soon as they show a lymphocy- 
tosis of 30 per cent, or over, or changes in the red blood cells, they are 
shifted to another department and thus removed from further contact 
with the poison. 

Treatment. — The treatment of poisoning with nitro-aromatic sub- 
stances is largely preventive. Those who are poisoned with these 
compounds are removed into the open air, stripped of all clothing, and 
their skin is thoroughly cleaned by scrubbing with a mixture of soap 
and coarse sand. Alcohol should not be given as a stimulant, ammonia 
preparations being used for the purpose. Sulphate of soda in the 
effervescent form is said to be effective for the nausea which is a 
prominent symptom in acute cases. The bowels are emptied and the 
drinking of large quantities of water is encouraged. There is no 
40 



626 INDUSTRIAL HYGIENE 

specific treatment for the more marked clinical conditions which are 
found as the result of chronic poisoning. The preventive treatment of 
poisoning by the nitro-aromatic bodies is dependent upon a very 
carefully devised system of ventilation and methods of dust and 
fume prevention and removal. This system of ventilation must 
provide for the removal of fumes resulting from the melting or remelt- 
ing of substances like tri-nitro-toluol, and, it must also introduce air 
in abundant quantities into the workroom without raising chemical 
dust when these poisonous compounds are handled in dry or granular 
form, or when they are being chipped or otherwise pulverized. The 
liberal use of exhaust vents placed in the floor or tables, to draw these 
fumes downward and away from the nostrils of the workers, are among 
the expedients which may be of service. 

Acid Burns. — Acid burns cause frequent and serious accidents in 
munition plants. All parts of the body which have been injured by 
contact with concentrated nitric, sulphuric or other acid, should be 
immediately flooded or bathed with large amounts of cold water. 
When burns have been produced by acids which have penetrated 
clothing, particular care should be taken to have those parts lying 
underneath bathed by allowing a stream of water to flow inside of the 
clothing. Immediately after bathing the parts, the acid which may 
have penetrated below the surface of the skin should be neutralized 
by bathing with a saturated solution of sodium bicarbonate until all 
foaming has stopped. The subsequent treatment of the burn with 
paraffin or with various ointments is exactly as in the case of other 
burns. 

Explosives Derived from- Analin. — A number of explosives derived 
from analin have been manufactured of late but their symptoms are 
like those produced by the nitro-aromatic group, largely related to 
disturbances of the blood, and a general depressing action. They 
produce cyanosis, weakness and dizziness particularly, and as a group 
have much in common with analin poisoning, as one would naturally 
expect. Like analin poisoning, these compounds of analin are readily 
absorbed through the skin. They do not, however, produce any 
destructive effect upon the red blood cells as is the case with the nitro- 
aromatic group. A diagnostic point of great importance which is 
emphasized by all those who manufacture products into which analin 
enters, is the very frequent examination of the blood of workers who 
are engaged in this work, to discover a reduction in the percentage of 
hemoglobin. This is held to be one of the most prominent symptoms 
of beginning poisoning. In connection with the manufacture of 
explosives derived from analin, poisoning by benzol and toluol must 
be considered since a large part of the analin is produced from these 
substances. 

Treatment. — In the treatment as well as the prevention of poisoning 
from the analin explosive compounds, cleansing of the skin is of the 
greatest importance, and for this, not only soap and sand, but diluted 
acetic acid or vinegar is found to be of service. The use of atropin and 



HYGIEXE OF ENVIRONMENT 627 

oxygen have been found to be quite effective when poisoning has 
developed. 

Local Irritant Effects of Modern Explosives. — Following the classi- 
fication laid down by Hudson, a number of chemical substances which 
enter in the manufacture of explosive compounds, or some of these 
explosive compounds themselves, produce local irritant effects. Some 
of these belong to the two groups already considered. Phenol or 
picric acid derivatives such as, tri-nitro-phenol, di-nitro-phenol, as 
well as di-nitro-chlor-benzol, tetra-nitro-methyl-analine, are among the 
more active local irritants. Tri-nitro-toluol in addition to producing 
poisonous constitutional effects as the result of inhalation and ingestion, 
may also produce local irritant effects. These agents cause severe 
itching together with a dermatitis which is similar to that of many 
other chemical irritants. The eruption may become eczematous, 
swollen and hot. The exposed parts of the body are not the only 
ones affected in this condition. Secondary infection may supervene. 
They respond fairly readily to the usual forms of treatment for irritant 
conditions from any cause. 

Fulminate of mercury is practically negligible as a constitutional 
poison, probably because it is manufactured and largely handled out- 
doors, but it may also act as a skin irritant. 

Tetrachlorethane. — Tetrachlorethane is a solvent for cellulose in 
the manufacture of a varnish for painting aeroplane wings in order to 
make them watertight. Its effects are essentially the same clinically 
as those of the nitro-aromatic bodies which we have already considered. 

Benzol and amylacetate are also used for the purpose of making 
solvents in connection with the painting of aeroplane wings. 

The occupational diseases here described must suffice to show the 
scope and range of interest of this new branch of medicine. 

THE HYGIENE OF ENVIRONMENT. 

Ventilation. — Doctors and welfare managers in industry have proved 
that bad ventilation causes headache, drowsiness, slowness of mental 
and muscular action, loss of appetite, pallor, a tendency "to catch 
cold" and predisposes to the development of infectious diseases. A 
worker whose vital powers, or " power of resistance" are diminished, 
is an easy prey to tuberculosis, pneumonia and other diseases. 

Ventilation that is effectively provided for in the modern sense, as 
employed by the sanitary engineer, is by far the most important and 
health-conserving measure in the entire field of the prevention of occu- 
pational diseases. In other words, errors in ventilation are at bottom 
the cause of the largest number of specific occupational diseases. 

A good system of ventilation is one that effectively removes con- 
taminated air as well as dusts, fumes, gases, excessive heat and moisture, 
and the substances which are generated either as a result of various 
industrial processes or by the burning of furnaces or various kinds of 
flames. Moreover, such a system should furnish a clean supply of 



628 INDUSTRIAL HYGIENE 

air of suitable temperature and moisture, which should be made to 
circulate freely to all parts of the factory quarters. The installation 
of an expensive ventilating system is not always necessary ; it may be 
even inferior to a simple and inexpensive arrangement. The constuc- 
tion of the factory, and the arrangement of its equipment so as not to 
interfere with the circulation of the air are of chief importance; each 
shop or factory loft has its own peculiarities of shape, size, height, 
window arrangement, furnishing, equipment and manufacturing 
needs. There is, therefore, no particular method of ventilation that 
is equally suitable for all factories. 

In certain instances, in order to make an industrial establishment 
healthful, it may be sufficient to enclose certain dust-producing machin- 
ery or portions of such machinery within metallic, air-tight chambers 
or compartments, or to place metallic hoods over them, through which 
dusts or fumes may be aspirated and carried away by euction fans, 
through a system of ducts. 

Every factory manager should have his plant carefully inspected, or 
in lieu of this, he should submit photographs and a detailed sketch of 
his establishment to a competent sanitary and medical expert in order 
to secure advice as to the particular kind of devices or arrangements 
best adapted to the need? of his particular factory. Any single pre- 
scription will no more fit all factories, than would a particular medicine 
cure all forms of disease. A person who has become habituated to a 
certain type of work and atmosphere is not as keen to perceive defects 
of ventilation as an outsider who has been trained to observe such 
conditions. Managers and foreman will repeatedly state that ordinarily 
they are not aware of certain odors or of other evidences of vitiated air 
unless they return to business after a long absence, as from a vaca- 
tion. The man "in the business" may be an expert in the technical 
side of his work, but he is often unable to detect or to correct sanitary 
defects obvious to the sanitary or medical inspector. 

Natural Ventilation is Best. — Natural ventilation, wherever possible, 
is best. It requires no mechanical contrivances to bring about a free 
circulation of air, and when it can be made suitable to the needs of 
the business and its employees, it is economical because it requires no 
costly system of supervision or maintenance. 

Natural ventilation is obtained through windows, chimney flues, 
doors, air-shafts, or through any other openings in the ceilings, roofs, 
walls or floors which may allow the free entrance of out-door air. 

There is a variety of devices which may be employed in the con- 
struction of a factory establishment, bv which natural ventilation may 
be assisted. 

Devices to Assist Natural Ventilation. — Perpendicular holes may be 
bored through the bottom rail of the upper window. Saw-tooth 
shaped roofs are frequently seen in foundries and other single-story 
factory buildings. These consist of a number of windows placed at an 
angle and projecting above the roof in rows, so that at a distance such 
roofs resemble the teeth of a saw. Such windows are usually made to 



HYGIENE OF ENVIRONMENT 



629 



face north, this light being most favorable for work, and allowing for 
a liberal intake of air. Monitor roofs are also excellent. Globe ven- 
tilators are frequently connected with saw-tooth windows. These 
ventilators are upright metallic tubes set in the roof, with an umbrella- 
like top beneath which there is a space; as winds sweep across the 
open space of this tube, a suction is created in the tube by which foul 
air is withdrawn from the room. This method is employed in theaters. 
A device which works on the same principle is used to ventilate the 
sleeping compartments of Pullman cars. 




Fig. 81. — Window ventilation is necessary but often insufficient. In this place 
apparently there is a liberal provision of windows, yet the crowding of employees, and 
the fumes and dust from manufacture make window ventilation alone insufficient. 
This is usually true even under very favorable circumstances when the weather is sultry 
and the air stagnant. (Courtesy of Engineering Magazine.) 

Windows, if placed on a central swivel can be hung so as to revolve 
on a horizontal or vertical axis; thus the entire window space can be 
utilized to admit air at a given time. The same result can be obtained 
by French casement windows, which, constructed like doors, can be 
swung open or closed, as desired. 

Small electric fans or large wooden blade ceiling fans (Fig. 82), such 
as are now familiar in offices, are of value in places where the air may 
become stagnant, in imparting a certain amount of movement or agita- 



630 



IX DC ST RIAL HYGIENE 




Fig. 82. — A desirable measure where a better method of ventilation is not available. 
A fan placed in the window assures some circulation at least. (Courtesy of Engineering 
Magazine.) 




Fig. 83. — Even a crude way of moving the air in a work shop pays. The uneconomi- 
cal and inadequate method of ventilation shown in this picture helps somewhat. The 
method that is coming to be generally recognized is to use a blower and exhaust system 
which introduces a sufficient quantity of clean air that is warmed in winter and cooled 
in summer, and which removes the vitiated air. (Courtesy of Engineering Magazine.) 



HYi.lEXE OF ENVIRONMENT 631 

tion to the air within the room (Fig. 83) which is essential for comfort 
and health. 

Unfortunately, many of these devices are ineffective because there is 
frequent conflict between employees who work in the center of a loft 
and those who are placed at or near windows; the former wish to have 
windows kept open and the latter usually insist upon closing them, 
especially in cold weather because of exposure to cold currents of air. 

Elimination of Dust.— There are certain industries, like mirror-mak- 
ing, in which special processes are carried on which demand the exclu- 
sion of dust; for this reason, windows are always kept closed in such 
factories. A fine wire mesh may make it possible to keep the windows 
open for purposes of ventilation, without admitting dust. In such 
industries, devices for supplying air that has been filtered of dust and 
regulated as to temperature, are of urgent necessity. 

Drafts Are Dangerous. — As a rule, ventilation is found defective when 
it is insufficient: at other times, however, it may be at fault. because of 
excessive drafts. These may make it difficult to heat premises econ- 
omically; moreover, there is a grave menace to health in drafts; they 
may cause stiffness of muscles and joints as well as predispose to 
respiratory diseases. If currents of air enter a room so that they strike 
employees with full force, the latter will almost always close up the 
inlets; therefore the mere provision of windows and fans without pro- 
tective devices to prevent discomfort from drafts is not sufficient. 

In certain bakeries, for instance, the men and women employed near 
the ovens where the temperature is quite high, must pass from over- 
heated rooms through windy and exposed corridors to reach other 
departments or to get to the dressing rooms and toilets, thus needlessly 
running the risk of contracting disease, especially during the colder 
seasons. Toilets, too, are frequently quite chilly or exposed to drafts. 
Likewise, men in steel foundries must often pass from one extreme of 
temperature to another hi the course of then work, or when they obtain 
a period of rest from then* excessive exertions and exposure to great 
heat. 

In still other factories — those which have been adapted to purposes 
for which structurally they were not intended — work must be carried 
on near elevator shafts, doorways, or passages which are almost con- 
tinually swept by powerful drafts. This condition constitutes a decided 
hazard to health. Revolving doors, or two sets of doors placed at a 
proper distance from each other, so as to form a vestibule or special 
corridor, may solve these difficulties. 

On the other hand, it is well to remember that warm, vitiated air 
rises to the upper part of a room and forms an almost distinct layer 
or stratum of air down to the level of the top of the doors, windows or 
other outlets. It is therefore disagreeable and harmful to work near 
the ceiling or on ladders, as painters do, or on balconies, as clerks 
and others frequently have to, unless an effective method of removing 
such vitiated air in the upper levels of rooms is employed. 

These are some of the problems which engage attention in many 



032 INDUSTRIAL HYGIENE 

industries. Means for keeping air in circulation or of overcoming 
excessive heat, cold, moisture or dryness or severe drafts are generally 
either totally ignored or imperfectly devised. 

Cases in which Natural Ventilation is Unsatisfactory. — There may be 
a number of conditions under which natural ventilation may be 
ineffective : 

1. This occurs when workrooms are very irregular in shape, so that 
air currents can reach certain spots, if at all, only by turning corners; 
or, when the arrangement of partitions, or the piling up of materials 
or of stock, creates enclosed spaces or "dead" areas, into which air 
currents can enter only with difficulty. This is one of the most common 
conditions encountered in factories, and in mercantile workrooms 
particularly. 




Fig. 84. — This shows the old method of fur beating in which bamboo sticks are 
employed and which creates considerable amounts of noxious dust. (Popular Science 
Monthly.) 

2. Natural ventilation may fail when the kind of dust which is 
generated in certain types of work is very considerable in volume and 
weight. This is exemplified in metal grinding, polishing, sandblasting 
and tumbling. 

3. When the process of manufacture gives rise to poisonous gases, 
dusts or fumes in a workroom it is necessary that they be carried away 
by specially contrived devices before they can be diffused in the air 
of the workroom to be inhaled by workers, in order to avoid injury 
to health. This is illustrated in the fumes which arise from the lead 
pots of linotype machines in printing shops, in the machinery of shoe 



HYGIENE OF EXYIROXMEXT 



633 



factories and in cleaning establishments where naphtha is used (Fig. 84). 
Fig. 85 shows a dust-removal device which is suggestive of a method of 
eliminating noxious dust which, in principle, may be widely applied. 

4. Where excessively high temperature exists (as in foundries and 
bakeries), or where there is excessive moisture in the air (as in laundries 
and sausage factories), natural ventilation is, as a rule, inadequate. 

5. And, finally, when natural air currents may have to be excluded 
because of the character of the work, as in furniture or automobile 
varnishing, where the entrance of air causes such rapid drying that 
streaks are left by each application of the brush. In gold-leaf laying 
natural air currents also interfere with the work, and also in mirror 
making it is necessary to prevent dust in the air falling upon the 
unfinished glass surface, through the use of special ventilating devices. 




Fig. 85. — This shows a vacuum device in which a motor causes a bamboo rod to 
oscillate vigorously about one thousand times per minute. The contrivance can be 
moved about on an overhead trolley and for practically all skins it replaces the oldfash- 
ioned bamboo stick beater and eh'minates dust hazards. This device was adopted by 
a number of fur manufacturers upon the writer's suggestion. (Popular Science Monthly.) 



Natural ventilation cannot be depended upon because of the capricious- 
ness of air currents, which in large lofts especially makes window 
ventilation most uncertain. 

Natural ventilation may be unsatisfactory also, because in our 
climate, atmospheric conditions are so extremely variable, that a 
system effective during the winter months may be absolutely useless 
during the warmer season. 

The Three Methods of Mechanical Ventilation. — When any of the above 
conditions exist and make methods of natural ventilation insufficient 



634 INDUSTRIAL 1IY(UKS1<: 

or ineffective, resort must be had to mechanical devices. Moreover, 
with a mechanical system of ventilation it is possible to keep the 
temperature and moisture of the air under control, and the air may be 
heated or cooled, and washed free or filtered of dust, before it is allowed 
to enter the workrooms. There are essentially three types of mech- 
anical ventilating devices which are the foundation of all mechanical 
systems, however complicated such systems may appear. 

1 . There is the plenum or blower method, by which a fan of adequate 
power blows or propels air into a given room or space (Fig. 86). The air 
current created by such a fan may be discharged directly into a room or be 
conducted through metal tubes or ducts of carefully calculated diameter 
which end in branches and finally discharge an air supply at selected 
points. In the use of this system a word of caution is necessary. 
When the points at which branch tubes discharge their air currents are 




Fig. 86. — Hollow column air-distributing system in the Ford shops. Through this 
system, ventilation, cooling and heating are carried on. (Courtesy of American Blower 
Company.) 

unwisely selected they may be either inadequate to ventilate the room, 
or they may direct chilling drafts upon the workers, thus interfering 
with their work; under the latter circumstances employees will, as 
already mentioned, find ways of shutting off the supply of air and make 
the system ineffective (Fig. 87). 

2. The vacuum or exhaust method of mechanical ventilation is one 
which depends on a fan that creates suction through a system of metal 
ducts or tubes, and extracts air that is impure, dust-laden, or charged 
with fumes or gases, and discharges such fumes outside the room or 
building. Contaminated air that is exhausted in this way may be 
collected or cleaned in specially devised chambers, and if the dust that 
is recovered in this process is of value a source of income may be 
derived from material that would otherwise be wasted; in certain 
industries this is a very important consideration. The vacuum or 
exhaust method should be so adjusted to machinery that any con- 






HYGIENE OF ENVIRONMENT 



635 



taminating substances that are generated in the process of manufacture 
are completely and immediately withdrawn at the point where they 
arise, thus preventing their dispersion into the air of the workroom. 
Too frequently the collecting tubes which are placed over machinery 
or other factory equipment, and which are intended to carry off or 
exhaust dust, gases or fumes, are placed at such a distance from the 
point where such contaminating substances are produced that they 
must be inhaled by the workers before they can reach the collecting 
tubes (Fig. 87). 




Fig. 87. — Drying room of the Universal Film Company. Note the risers from the 
floor through which air of proper temperature is blown into the room. (Courtesy of 
American Blower Company.) 



3. The third method is the balance system, a combination of blower 
and vacuum. Air is forced into the room through one set of tubes and 
extracted through another set. Wherever the rooms to be ventilated 
are very large this is a particularly valuable method. The inlet or 
opening through which air is expelled must be carefully constructed 
and placed, otherwise an expensive installation may be rendered abso- 
lutely worthless. 



030 



INDUSTRIAL HYGIENE 



A technical adviser is the host judge as to the proper method to 
employ. His special knowledge enables him to ventilate a rathskeller 
or a subbasement, as effectively as a modern loft, restaurant, or the main 
floor of a department store. When a mechanical method of ventilation 
fails, it is due either to poor judgment in regulating the power or the 
placing of fans, or in the diameter of the conducting tubes and the 
points at which they discharge air. Expert advice as to the engineering 
data for the installation of such devices is in the end a great economy. 




Fig. 88. — A boiler room of unusual character. In boiler rooms, as a rule, no attempt 
is made to provide comfortable working conditions. In this picture is shown a boiler 
where the excessive heat is exhausted through a hood, making the boiler room comfort- 
able. The heated air which is exhausted through a system of ducts can be utilized for 
heating the factory plant, after being filtered and sufficiently moistened. (Courtesy of 
Engineering Magazine.) 

The subject of ventilation in relation to the occupational disease 
is too extensive to be dealt with at greater length in this section, and, 
as its importance warrants. 

Heating. — A good heating system in a factory or workplace is inti- 
mately related to the problem of ventilation. The temperature of 
the workplace influences the health, comfort and efficiency of workers. 
A heating system may be costly and yet fail to accomplish its purpose. 
The sanitary engineer who is truly expert in installing a ventilating 



HYGIENE OF ENVIRONMENT 637 

system is not content merely to provide exhaust and blower fans, but 
must often given attention as well to the temperature of the air which 
is forced into the workplace, to provide a proper percentage of moisture 
and freedom from dust and fumes. 

Heating by stoves is uneconomical, and, as a rule, ineffective in large 
establishments. Hot water, which is a waste product in mam' indus- 
tries, has been utilized for heating by being made to circulate through 
radiator coils placed throughout a building; it is not as practical and 
economical a method as steam-heating. The distribution of heat in a 
building is readily taken care of by any competent sanitary engineer. 
Too many establishments are overheated; this defect is often as bad 
in its results as is a lack of heat. Overheating causes fatigue, headache 
and discomfort; it lowers health and conduces to accidents. Extreme 
heat may cause heat -exhaust ion, joint and muscular pains, choleraic 
symptoms, and predispose to disease. The air in offices and factories 
is often allowed to become so much drier than the outdoor air that the 
employees who pass from one to the other are frequently affected with 
catarrhal conditions and other diseases of the nose, throat and air 
passages. 

When heat is extreme screens of asbestos or other material interposed 
between workers and the furnaces at which they work may lessen the 
heat very considerably. Forced air blasts may also help to lower the 
temperature of a shop. 

How to Light a Factory. — A good system of lighting is more than a 
matter of mere comfort. It frequently prevents accidents and increases 
the efficiency of workers, especially when they are engaged in delicate 
manipulations or work that requires close application; it also does 
away with headache, dizziness, general sluggishness, inflammation of 
the eyes, fatigue and nervous symptoms and the other ill effects of 
eye-strain. Engravers, type-setters, weavers, lamp-testers, diamond- 
cutters, proofreaders, etc., are notoriously subject to eye-strain and 
often suffer permanent injury to sight. 

Lights may be objectionable either because they are too dim, or 
excessively bright and glaring (Figs. 89, 90). Lighting, like ventilation, 
is best when it is natural. Modern methods of steel and concrete con- 
struction make it possible to utilize 80 or even 90 per cent, of the total 
wall surface of a building for windows. With the old method of brick 
and wood construction, and with wooden window frames, this was 
impossible; nevertheless, even in buildings of the latter sort about 50 
per cent, of the wall surface can and should be devoted to window space. 
With the marked variations in the length of days during the different 
seasons of the year, natural lighting cannot be exclusively depended 
upon, no matter how well provided. 

Skylights, and more especially saw-tooth roofs, permit a maximum 
amount of light to enter the workplace. They can of necessity be 
constructed only on single-floor buildings or on the top floor of a high 
building. 

When a loft is very deep and wide it may be poorly lighted in the 



c>:;s 



INDUSTRIAL HYGIENE 



center despite numerous windows; in such a case, work requiring close 
attention and bright illumination, as in jewelry-making, should not 
be attempted in the center of the loft unless well-shaded artificial lights 




Fig. 89. — Pupil contracted in a bright 
light. Muscles of eye also contracted. 
This constant cramp-like contraction of 
muscles of the eye causes fatigue and 
eye-strain and conduce to accidents. 
(Courtesy of New York Edison Co.) 




Fig. 90. — In moderated and well-shaded 
light the pupil is not contracted. 



of sufficient illuminating power are supplied. Windows must be clean 
to prevent obstruction to the entrance of light. If a building is crowded 
in between other buildings it may be impossible to properly illuminate 
its lower floors especially, without resort to artificial lighting. A light 




Fig. 91. — Each of these little rooms receives the same amount of. light. On the 
left, the dark walls absorb most of the rays; on the right, the light-colored walls reflect 
the rays of light causing a most marked contrast. (Courtesy of New York Edison Co.) 



coat of paint on the walls of adjoining buildings improves natural 
lighting. Walls and ceilings inside of factory buildings should espe- 
cially be painted with light colors, — a light green or tan, — and kept 



HYGIENE OF EXVIROXMEXT 



639 



clean (Fig. 91). It is important to prevent a strong glare, whether 
natural or artificial light is employed (Figs. 92, 93). 




Fig. 92. — A bright light that is not shaded shines directly into the eyes and causes 
fatigue and accident. (Courtesy of New York Edison Co.) 




Fig. 93. — A shade protecting the eyes from the bare light. (Courtesy of New York 

Edison Company.) 



Arrangement and Construction of Windows. — To prevent the glare that 
results when the sun shines directly into a loft, either the use of window 
shades or of frosted, ribbed, or other transluscent glass may be neces- 
sary to subdue the light. Windows should extend upward as near 
the ceiling as possible. Stock, machines, and equipment should, if 



640 INDUSTRIAL HYGIENE 

possible, be arranged so as to interfere as little as practicable with 
natural light. The lower panes should be transparent, as it is restful 
and relieves the strain upon the ocular muscles of workers to look 
out into the distance occasionally. The larger the window panes the 
smaller the ratio of obstructing framework is. Often the very factory 
managers who pride themselves on their attention to details with 
reference to factory lighting permit gross defects to exist owing to a 
lack of proper understanding of the essentials of good lighting. 

In some offices the clerical force is frequently seen engaged in work 
that is trying to the eyes, and yet the desks are placed in the center 
of a very large floor at a distance from the source of light, or else the 
workers directly face the light, thus suffering from the results of the 
glare ; in still other cases the employees are so seated that their bodies 
intercept the light. It is best to have light coming from only two sides 
of a room, and those opposite each other, except when the depth of a 
loft is excessive. Working in the dark or in very dim light is harmful; 
its extreme ill-effects are seen in miners, who frequently develop 
nystagmus, or "dancing pupils;" a condition in which the eyeball 
oscillates rapidly from side to side. The latest studies seem to indicate 
that a constrained posture which requires an upward turning of the 
eyes while at work adds its influence to the effect of dim lights to 
produce nystagmus. The effect upon the eyes and nervous system of 
girls who work for long periods in a dim red light packing photograph 
films, or upon employees in moving-picture theaters, may ultimately 
be very harmful. 

Excessively Bright Lights.— When artificial lights are too brilliant 
they should be shaded so that the light falls upon the work; especially 
should one avoid placing such lights on a level with the worker's eyes, 
causing it to shine directly into the eyes, thus inducing fatigue and 
creating a liability to accident. 

In an investigation of a block of office buildings that was conducted 
by the New York City Department of Health in one of the busiest 
sections of the financial district of New York City, it was found that 
somewhat over 85 per cent, of 2382 persons employed in the offices 
in this block were compelled to use artificial light in their every-day 
work, and in many instances in the middle of the day. Usually the 
lights were placed at too great a distance from the desks or typewriters, 
or they were too dim. In other cases excessively bright lights were 
placed very close to the work desk and caused a glare, or a too highly 
polished desk caused such a glare, or a shade of improper style was 
employed. On the basis of this investigation it was recommended that 
in addition to ceiling lights, desk lights of low candle-power should be 
provided and placed at a distance of not over nineteen inches and at 
an angle of 45 degrees to the left of the field of work in the case of right- 
handed persons. 

Parts of machinery having glistening or polished surfaces which keep 
moving continually before the eyes of the employees constitute a source 
of eye-strain, fatigue and nerve-strain; this applies with equal force 



HYGIENE OF ENVIRONMENT 



641 



to the handling of materials which have a high gloss or polish. Such 
conditions impair efficiency and conduce to accidents. 

In foundries, and where electric welding with the oxyacetylene flame 
is done, a brilliant light is produced ; the eyes should be protected from 
such light by wearing amber or natural-tinted glasses. 

Safety goggles, of which there are a large variety on the market, 
are very effective, and are absolutely necessary in certain occupations 
such as electric-welding, furnace work, or wherever excessively bright 
light from electric flashes or any other source may exist, because they 
prevent irritation and inflammation of the eyes as well as injuries from 
flying particles (Figs. 94, 95). 




Fig. 94. — Head mask for protection from sparks and blinding glare in electric- welding. 
(Courtesy of U. S. Steel Corporation.) 



Goggles should be light, allowing no metal parts to touch the skin, 
and be re-enforced so as to protect the eye in case the glass is broken. 
They should be constructed with lateral guards that will allow a wide 
field to be seen and yet prevent flying particles of any sort to enter the 
eye from the sides (Fig. 96). 

While it is not strictly relevant to the question of lighting, it may 
not be amiss at this point to call attention to the fact that physicians 
who have studied the eyes of employees engaged in grinding, polishing, 
and buffing, report that the shower of fine metal or mineral particles 
against the highly sensitive, transparent cornea continued for months 
41 



642 



INDUSTRIAL HYGIENE 



or years, causes very numerous pinpoint scars; these can be readily 
observed with a magnifying glass. Such scars reduce the sharpness of 
vision down to 50 per cent, or even 5 per cent, of the normal. 

A very large percentage of eye injuries that lead to serious impair- 
ment of vision and even to blindness, are the result of failure to provide 
and wear safety goggles. The foreign bodies that lodge in the eye set 
up frequently a dangerous inflammation; the attempts of fellow-workers 
to remove them from each other's eyes have frequently produced 
infections that have resulted in blindness. Only a physician should 
be permitted to treat even the slightest eye injuries and remove foreign 
bodies. Delay in securing skilled help frequently causes permanent 
damage. Injuries to the eyes are probably the most common industrial 
accident. 




Fig. 95. — Head masks worn while babbitting in steel works. 

Corporation.) 



(Courtesy of U. S. Steel 



A near-sighted employee, whose defect is not corrected by properly 
fitted glasses invites accidents; he is compelled to bring his face too 
close to his work, and is in greater danger than persons of normal vision 
of inhaling poisonous dusts, gases or fumes, if these are associated with 
his occupation. 

Paint and Cleanliness Help Lighting. — Natural and artificial lighting 
are very much aided by painting the walls, ceilings, and equipment, so 
far as possible, a dull white, a light tan, or a greenish-gray color. Sur- 
faces having enamel finish cause reflections that fatigue the eye. 

Abundant light, and walls painted in light color, make dirt so con- 
spicuous that their provision has a natural tendency to produce cleanli- 
ness in an establishment. One company in recognition of this fact has 
caused every corner in its buildings to be painted white; it reports that, 
as a result, there has been a marked improvement in cleanliness; the 



HYGIENE OF ENVIRONMENT 643 

workers are not so apt to expectorate or to throw waste matter in 
corners which are well lighted. 

Facts as to Artificial Lighting. — In installing artificial lighting systems, 
much depends upon the type of light which is employed, its intensity, 
proper shading, and upon its being placed at a proper level. Attention 




Fig. 96. — Goggles to protect eyes from flying chips and dust. (Courtesy of U. S. Steel 

Corporation.) 

to each of these details is of great importance. For instance, a light 
may be so shaded, and placed at such a level with relation to the eyes 
of workers as to eliminate a glare, but may be too dim and give off 
excessive heat— a gaslight for example. Or, again, lights may be bright 
enough and well shaded, but placed in such bad position that the bene- 



644 INDUSTRIAL HYGIENE 

ficial effect is lost and an otherwise adequate light is dissipated, so that 
the workbench or desk is left in comparative darkness. 

Lights should be so adjusted that pronounced shadows are elimi- 
nated; where shadows are produced the quality of work is interfered 
with, eye-strain is favored and accidents from tripping or from failure 
of rapid accommodation of the pupils to changed conditions of lighting 
may occur. Green, blue or violet mercury lamps, such as are used by 
photographers and others, are usually unpleasant and irritating to the 
eyes, because the most active and powerful rays of light — the actinic 
rays — are here utilized. Such lamps are of service only in work which 
requires very close scrutiny. Electric lights, especially tungsten lamps 
are, generally speaking, the most practical. Incandescent gas mantles 
give a bright white light, which requires careful shading, but when used 
in large numbers they are objectionable because of the heat and gases 
of combustion that they generate; when this is the case, special care 
should be given to ventilation. 

Artificial lights are usually placed near the ceiling, so as to illuminate 
the workroom in general, and additional lights are adjusted close to 
machines and at special points so as to give a maximum amount of 
light where it is most needed. To secure general illumination of a 
workroom, artificial lights, especially powerful tungsten lamps (100 to 
1000 watt) should be dispersed in sufficient number at carefully esti- 
mated distances from each other, near the ceiling. No general rule 
for the adjustment and disposition of lights can be given that is applic- 
able to establishments that vary greatly in their constructive and other 
features; each problem must receive individual attention. 

Lights that are placed close to machines or to workbenches give 
what is known as "local" in contradistinction to "general" illumina- 
tion. It may be stated, as a general rule, that no factory or office 
should depend upon either "local" or "general" illumination alone; it 
is best to combine the two. A "general" system of lighting usually 
fails to provide illumination sufficiently bright for work that requires 
care and close observation. On the other hand if only local lights are 
employed and placed at selected points near machinery or work- 
benches, the rest of the room is left relatively dark, and employees may 
be dazed in attempting to move about, and as a result accidents may 
occur. 

When ceilings and walls are painted white or in other light colors, a 
white enameled metal or other opaque bowl placed beneath a ceiling 
light reflects such light upward upon the ceiling and is diffused over the 
space beneath ; this is known as indirect lighting. If instead of a metal 
bowl or reflector, a translucent glass bowl is employed, the light in 
part passes through the bowl, and in part it is reflected to the ceiling 
and thence diffused; this is known as "semi-indirect" lighting. Both 
the indirect and the semi-indirect methods of lighting are excellent for 
general illumination, both prevent fatigue and eye-strain, but the 
semi-indirect method, while not quite as restful as the indirect, is more 
economical. 



HYGIEXE OF EXYIROXMEXT 



645 



Washing Facilities. — Personal Cleanliness. — When working people 
handle poisonous metals, liquids or chemicals, as, for example, lead, 
arsenic, mercury or anilin dyes, or infectious materials, washing facili- 
ties should be adequate, and hot water, soap and brushes should be pro- 
vided. Signs printed in the language best understood by the workers 
should be conspicuously posted, to give warning of the dangers that are 
connected with the work, unless strict cleanliness is maintained. Those 
employees who handle dangerous chemical substances should be given 
a ten or fifteen-minute period deducted from factory time, to wash 
befor eating lunch and before going to their homes at the end of their 
day's work. If the time is deducted from their lunch period, or, if the 
number of faucets or other facilities available for washing purposes 
are inadequate, employees will, as a rule, fail to wash. 





* 


/ 






m 


■ 


_ 




^ 


f ■ i ^ 





Fig. 97. — Shower baths and wash basins in room warmed by radiators. Note the plunge 
in center. (Courtesy of U. S. Steel Corporation.) 

These rules hold equally true as to the use of shower baths. In 
trades in which dangerous dusts exist, and in any. trade where the 
worker gets very hot or very dirty, shower baths are of the greatest 
value in removing poisonous or irritating dusts from the hair and skin, 
and are therefore a protection to health and an economy to the business 
in the long run. Baths are splendid tonics to those w T ho are fatigued, 
especially if they are of short duration, and neither too warm nor too 
cool. Workers will abstain from the use of baths if the temperature 
of the water is too low; moreover, cold water is never as effective as 
warm water in cleansing the skin. It should be borne in mind that 
employees ignore any welfare measure which in any way causes discom- 
fort or a loss of time. A worker who enjoys the tonic and cleansing 
effects of a bath is more likely than otherwise to be alert to cleanliness 
in the home. 

In occupations in which dangerous dusts or chemicals are encoun- 



646 INDUSTRIAL HYGIENE 

tercel, washing should not be left to the option of the employee but 
should be enforced by a foreman or other supervisor, who should be held 
responsible for compliance with this most essential regulation. 

In addition to those requirements, which have already been alluded 
to, care must be exercised that the floors of shower baths are not too 
cold or slippery; for this purpose, wooden grids or rubber mats should 
be employed, and they will be found to add not only to the comfort of 
employees but to prevent accidents from slipping as well. The floors 
of shower baths should be constructed of some impervious material, 
properly graded and drained, to prevent accumulation of water. 

Soap is essential for washing, and receptacles for powdered or liquid 
soap, of which many kinds are sold, will be found to be the most practi- 
cal, sanitary and economical. 

When troughs are provided for washing purposes the drain-pipe 
opening should, never be plugged, so as to prevent filling of the trough 
with consequent transmission of disease from worker to worker, as a 
result of washing in standing water used in common by a number. 
A wire-mesh screen should be fastened about four inches above the 
bottom of the trough to prevent the use of standing water (Fig. 97). 

Lockers for Clothes. — Lockers are not luxuries but a necessity to 
people who are employed in an atmosphere heavily charged with odors 
or with poisonous dust or chemicals that may adhere to the clothing. 
Lockers should be provided so that employees may be able to change 
their street clothes for special work-clothes or overalls. The locker 
facilities must be such that the street clothes should not be soiled or 
contaminated by contact with the work-clothes; for this reason, in 
trades which are especially characterized by dust, dirt or fumes, sepa- 
rate compartments should, if possible, be provided in each locker for 
the two sets of clothing. Arrangements which provide for the keeping 
of separate wearing apparel save the employees from becoming soiled 
with the poisons or other harmful substances that they handle and help 
them to prevent bringing these dangerous agents into their homes. 

Cleanliness of lockers and of locker rooms must be strictly main- 
tained. Locker arrangements should not be installed in workrooms if 
possible; they should be placed outside the workroom, where the 
clothes will not be covered with trade dust. Locker rooms should be 
well lighted and well ventilated; light and air in abundance are in this 
case, as in all others, among the best germ destroyers that we have. 
If hooks only are provided for hanging up clothes, they should be so 
placed that the clothes on adjoining hooks will not touch. It is a 
frequent practice to place hooks on opposite sides of a beam or board, 
so that clothes of different persons are in contact; where wardrobe 
space is limited and economy is essential, two parallel cross boards, at 
least six to eight inches apart, will allow the placing of hooks so that a 
safe distance will be maintained between clothes on opposite sides. 

To help the drying of street clothes on rainy days, steam pipes 
placed around the walls or close to the lockers are very effective. 
This frequently prevents disablement of employees from colds, pneu- 



HYGIENE OF ENVIRONMENT 



647 



monia, etc., especially when, in addition to these, facilities^for drying 
wet shoes and socks or stockings are provided. In a number of 
factories the provision of dry socks and stockings and of umbrellas 
has greatly assisted in preventing sickness resulting from exposure to 
rain and snow. 

A locker which is most sanitary and in the long run most economical 
is one made in the form of a small steel closet, with slits or perforations 
which allow for ventilation. Locker rooms should be provided with 
seats to facilitate dressing and undressing; small folding seats which 
are kept in the lockers are of service and do not take up additional 
space. Air-tight lockers are frequently found in use and are undesir- 
able from a sanitary standpoint. In establishments where a number of 
female employees are at work hats should not be permitted to be placed 
on top of each other or close together, as is so frequently done; the 
latter practice has been known to transmit pediculi from one to many 
employees. 




Yig. 98. — The old way of supplying drinking water. A dangerous method. Tuber- 
culosis, syphilis and other infectious diseases are thus transmitted. (Courtesy of TJ. S. 
Steel Corporation.) 

Drinking Cups and Water Supply.— It is accepted as an axiom that 
a cup, glass, pitcher, spoon, fork, or similar article, if used in common 
by two or more persons, may transmit tuberculosis, syphilis or other 
infectious disease (Fig. 98). This is particularly true of drinking cups. 
Paper cups for individual use are ideal although expensive. A good 
solution of this problem is to supply each employee with an ahmiinum 
cup at cost price, or. better still, to provide sanitary drinking fountains 
placed where they are readily accessible (Fig. 99). If the supply of 
drinking water is placed at a distance from a group oi workers, or if 
for other reasons it is not easily available, the employees will omit to 
drink the quantity of water which is requisite for health, or else drink 



648 



INDUSTRIAL HYGIENE 



excessive quantities at infrequent periods. A liberal supply of drinking 
water is ot special importance to those whose work is severe and causes 
profuse perspiration. A sufficient and good water supply is a health asset. 
Moreover, the lack of such water supply frequently stimulates a strong 
craving for alcoholic drink. 

Water should be neither too cold nor too warm. One of the most 
frequent causes of intestinal trouble in men who work where heat is 
excessive is the drinking of large quantities of cold water. Water 
should be cooled by means of a cooler or other refrigerator, or ice be 
packed around the container. It is unsafe to cool it by placing ice 
into it; intestinal disorders and typhoid fever have not infrequently 
been caused in this way. If water is unpalatable, employees will 
abstain fuom drinking it. When the source of water supply is known 



Hv 




> 


1 1 flHHL il * 

■Bar J x ^k HI HHL U 



Fig. 99. — Drinking fountain close to the furnace where men can satisfy their thirst 
readily. Men doing such work as this require an abundant supply of drinking water 
near at hand. (Courtesy of U. S. Steel Corporation.) 



or suspected to be impure, special devices should be installed to purify 
it. The sanitary drinking fountains provided should be so devised 
that the water bubbles up high, and so that it is practically impossible 
for an employee to place his lips against the opening from which the 
water bubbles. A metal ring or collar is frequently placed in such a 
position that the lips are kept at a distance from the spout of the 
fountain. Recent studies have proved that germs may be transmitted 
from the lips or tongue of an infected person who places them in con- 
tact with the spout of the fountain, if the water bubbles up only 
a short distance under low pressure. These studies have shown that 
the germs are kept suspended and dancing in the water for several 
hours. By experiments it was demonstrated in a western university 
that certain selected varieties of germs could be placed in the spout 
of water by contact with lips that had been smeared with such germs, 



HYGIENE OF ENVIRONMENT 649 

and that the latter were recovered several hours later from the bubbling 
column of water. It was learned in one instance that a severe epidemic 
of septic sore-throat, occurred anion"' a group of students who drank 
from a bubbling fountain which had been used by a person whose lips 
had touched the spout and who was suffering from this disease. To 
prevent any infectious matter remaining suspended in a column of 
bubbling water the spout of the fountain should be so constructed that 
the water bubbles up at an angle of at least 15 degrees, and so that it 
falls to a side immediately and is drained off with all its contents. 

Towels. — Towels, when used in common, may transmit syphilis, 
gonorrhea, tuberculosis, trachoma and other diseases. The paper 
towel, although usually effective, has a limited value for industrial 
use, because it does not aid in removing dust or dirt that adheres to 
the face or hands by friction, as the cloth towel frequently does. In 
addition, the paper towel is relatively very expensive. 

Several methods have been devised to overcome the practical diffi- 
culties connected with the furnishing of individual towels to employees. 
In some establishments very satisfactory results have been obtained be- 
having a porter or other employee distribute individual cloth towels 
to .employees two or three times a week. Each employee receives a 
clean towel only upon returning the one that has been soiled. This 
method is especially effective if a charge equal to the cost price of a 
towel is made for failure to return one. 

Another satisfactory arrangement is the following: A metal ring 
is securely attached to one corner of each towel; a sufficient supply of 
towels for the day's needs is placed on a shelf about four feet above the 
floor. A steel rod is firmly secured to the shelf at one end and passes 
perpendicularly upward through the metal rings in each towel, makes 
a short bend, and then passes downward and is fastened into the floor 
or wall. When it is desired to use a towel it is lifted from the shelf, 
drawn along the rod, and after being used it is dropped into a basket 
on the floor; it is at all times attached to the rod and remains securely 
fastened until the ends of the rod are unlocked. 

Last, a new mechanical device containing a roll of towel cloth that is 
about twenty-five feet or more in length is now being tried. Each 
employee is given weekly a certain number of special coins; when a 
towel is desired one of these coins is dropped into a slot and a sufficient 
length of towel is released. After use the portion of towel that has 
been released is mechanically drawn into a special compartment, so 
that it cannot be used again. Certain mechanical towel rolls of this 
type are not provided with a device for removing the used portion 
of the towel-roll; the latter machines make it possible to use over and 
over again a section of cloth that has previously been drawn from 
the machine, thus making it in no manner superior to the deservedly 
condemned roller towel. 

To prevent the loss of individual drinking cups and towels that may 
be supplied to employees, a small drawer having a compartment just 
large enough to hold these articles and furnished with lock and key 



050 INDUSTRIAL HYGIENE 

is very useful, if built into the workbench or wall of the workroom. 
If a drawer of this character is made too large the workers will, as a 
rule, store their lunches and other undesirable articles in them; lunch 
packages, above all things should never be taken into workrooms, 
especially where dusty or chemical processes are carried on. 

Toilets. — If toilets are poorly constructed, filthy, or inadequate in 
number, so that those who wish to use them during rest periods, 
lunch hours or at other times must wait their turn, or if they are 
located at a distance from the workroom, employees will avoid their 
use as much as possible. Such unfavorable conditions with respect to 
the location and character of toilets may upset the regular physio- 
logical habits so essential to the health of employees and lead to chronic 
constipation. This is illustrated sometimes in the case of girls, who, 
in order to reach unfavorably situated toilets, may have to pass through 
lines of male employees; the fear of making their needs conspicuous 
restrains them from availing themselves of these facilities, with conse- 
quent discomfort, and, very likely, ill-health as well. The toilets 
that are provided should be modern in construction as regards sewer 
connections, flushing, ventilation and cleanliness; privacy should be 
assurred those using them. Water-closet apartments for the two sexes 
should be separate and as far apart as possible. The toilet rooms for each 
sex should, if possible, be situated in different parts of the building. 
Where water-closet apartments adjoin, the partitions between them 
should be sound-proof and of solid construction, so as to ensure privacy 
and prevent the escape of odors. Toilet compartments should be 
separately vestibuled and plainly marked, so as to indicate for which 
sex they are intended. The number of toilets and urinals required 
for a given number of employees in any establishment, together with 
specific details as to the materials and construction of floors, sidewalls 
and partitions, are, as a rule, definitely laid down in the various State 
labor laws, which should be consulted by employers. In fact the 
State labor laws will be found to be equally specific as to the number 
of wash basins and similar comfort facilities that are required in factory 
buildings. 

In moderately large establishments, toilets should, if possible, be 
situated on every floor; in no case should they be distant from the work- 
room or otherwise inaccessible. They should not be placed outside 
the building, nor should they be placed in the middle of a loft unless 
they are in direct communication with the outer air through air shafts 
or other means. Toilets must not be made to depend for their ventila- 
tion upon openings or windows leading into the workrooms; they should 
communicate with the outer air by means of windows and be provided 
with fans or other suitable devices for proper ventilation. Facilities 
for washing should be immediately adjacent to the toilets, and soap 
and towels should be provided; also, signs calling attention to the 
necessity of washing the hands, should be conspicuously placed. 

Sweeping and Cleaning of Premises. — The general cleanliness of a 
business establishment is a fairly reliable index to the healthfulness of 



HYGIEXE OF ENVIRONMENT 651 

the workplace and of the attitude of the employer or manager toward 
questions affecting the welfare of employees. Thorough and frequent 
cleaning of floors, walls, furniture and machinery is conducive to 
comfort and to health and may be a means of preventing accidents. 
Keeping windows clean and walls white are also of value as a means of 
improving lighting. Fire hazards may be considerably diminished by 
prompt and effective disposal of rubbish, refuse and trade waste. 
Moreover, general cleanliness affects the tone and character of em- 
ployees; clean surroundings in the factory tend to create and to 
confirm habits of cleanliness. 

It is improper and may be dangerous to permit sweeping or dusting 
of the floors, walls and fixtures of a workroom just before the day's 
work is begun, and still more so during work hours or just before the 
lunch hour. Sprinkling water on floors, or the use of a damp broom or 
cloth for sweeping and cleaning, are advisable. There is purchasable 
in the market a soft broom which has a metal hood attached directly 
above the brush, and which, if used with damp sawdust or liberal 
quantities of wet piece? of newspaper, or one of the so-called "dust 
settlers," is fairly effective in preventing the raising of dust. When 
the use of a vacuum cleaner is not practicable, a dampener or settler 
is absolutely essential, because dry sweeping raises dangerous dust, 
scatters it about and causes a large portion of it to be distributed upon 
the walls and furniture. 

The best method of cleaning and sweeping, in spite of the fact that 
many protest that it is impractical, is by means of the vacuum cleaner. 
Already many factories have installed this method, and the time is 
not far distant when the vacuum method of cleaning will be in well- 
nigh universal use, effecting safety, and economy as well, in spite of the 
initial cost. Vacuum suction can be made powerful enough to serve 
in many industries. 

Little attention is usually given to the selection of the person who is 
to do the dusting and sweeping, and, frequently, one or several boys or 
girls, or frail individuals who give evidence of susceptibility to tuber- 
culosis, are assigned to the task. The protection of the sweepers and 
cleaners is ait important consideration, and therefore, even if sweeping 
is done after work hours, a vacuum or dustless method should be 
employed. While a handkerchief, such as is often worn over the nose 
and mouth in certain dangerous and dusty occupations, to serve as a 
mask or respirator, is utterly worthless as protection against poisonous 
dust, it may be of some service as a protection to sweepers where a 
better means of protection, namely, a respirator, is not available. 

Spitting and Cuspidors. —Spitting should be strictly prohibited 
in the workroom, as indeed in all public places, because the 
germs of tuberculosis, pneumonia, influenza and other serious 
diseases, which even the sputum of healthy persons may contain, 
are distributed in the air when the sputum dries and is inhaled 
by those in the workroom. The habit of spitting is particularly 
common among members of certain trades who chew or smoke while 



652 INDUSTRIAL HYGIENE 

at work; such a habit when characteristic of a trade has a three-fold 
danger: (1) There is the danger to others from the germs in the dried 
sputum; (2) when spitting is an accompaniment of smoking, a distinct 
fire hazard exists from lighted cigars, cigarettes and pipes; (3) should 
the dust about the premises be poisonous, much larger quantities 
than ordinarily, are likely to be carried into the mouth through smok- 
ing or chewing. 

Employees usually refuse to expectorate into their handkerchiefs; 
cuspidors should therefore be placed near the work benches of those 
who cannot control the spitting habit. A large variety of cuspidors 
are available. The essential points to be kept in mind in selecting 
them are the following; 

Whatever the material of which they are constructed they should be 
shaped and and weighted so as not to tip over readily; there should be 
no angles or sharp corners to make cleaning difficult, and for the same 
reason the neck of the cuspidors should be wide, and, if possible, they 
should be constructed of material that has a glazed or enameled finish. 
Furthermore, they should contain a disinfectant solution of chlorinated 
lime or a w T eak carbolic or bichloride of mercury solution. When the 
use of disinfectant solutions is found impracticable water should be 
place in the cuspidors. Dry saw^dust within or around the cuspidors 
should never be permitted, as it only hastens the drying of sputum and 
can readily be blown about. When an employee is persistently careless 
and expectorates upon the floor, in spite of the fact that cuspidors are 
provided, he should be warned that he is endangering the health of 
others. If public-spirited foremen or fellow-workers would be willing 
to notify health officials of such violations and give legal testimony 
against such obstinate offenders with whom education and persuasion 
fail, much could undoubtedly be done to root out the practice. 

Wlien cuspidors of suitable character are not provided it is safe to 
permit workers to expectorate into a properly drained sink which is 
not employed for washing dishes or in the preparation of foods. Surely, 
it is no more dangerous to ordinarily expectorate into a sink than to 
clean one's teeth and to discharge the mouth rinsings into the basin, 
provided the basin is flushed so as to promptly wash down the sputum. 
As a matter of fact the French have devised a cuspidor, based on this 
idea, w T hich is connected with the w^aste pipe, trapped, and has a flushing 
system. 

Paper cuspidors, w T ith or without metallic holders, can be obtained 
rather cheaply, and they should be burned after use, thus doing away 
with the labor and danger of cleaning metal cuspidors. These paper 
cuspidors are made so as to hold water (w^ater one inch in depth is 
sufficient) . Another excellent type of cuspidor is a shallow iron or steel 
enameled basin, about ten inches in diameter, with a funnel-shaped 
removable cover having a large opening in the center; it is better still 
to dispense wdth the cover if the cuspidors contain about an inch of 
water and are cleaned often enough. Cuspidors should be cleaned out 
of doors, if possible, flushed with a hose and boiling w T ater and the 
contents drained into a sewer. 



HYGIENE OF ENVIRONMENT 653 

Pottery and china cuspidors break readily and are, therefore, too 
expensive. 

Lunch Rooms. — Xo employee should be permitted to eat lunch in the 
shop, especially if poisonous dust or chemicals are handled there. Xor 
should workers be compelled to eat in dark, dirty parts of shops or 
factories which are too poor to be put to other uses. In the case of male 
workers ii is frequently found even since prohibition has been put into 
effect, that they resort to the nearest saloon, where they now exist, the 
meanest of which frequently offers more comfort and cleanliness for 
lunch purposes, than many workshops. There has been a steady growth 
in the number of factories and shops which provide rooms especially 
designed to serve as lunch rooms. When proper care is taken to provide 
washing facilities, toilets, and lunch rooms, the corner saloon is fre- 
quently put out of business. Lunch rooms should have no connection 
with the workrooms ; in other words the small space in the corner of a 
shop which is more or less curtained off does not answer the purpose of a 
lunch room and may be a source of danger in certain occupations. This 
danger has, in fact, been recognized, and legislation exists which com- 
pels employers to furnish properly walled-off lunch rooms wherever 
lead, mercury, arsenic and other dangerous chemicals are used. 

Lunch and Rest Periods. — All employees and especially girls should 
receive a lunch period of an hour. Often the girls themselves request 
the half-hour luncheon period in order to secure a half-holiday on 
Saturdays; but to permit this arrangement is a short-sighted policy, 
especially in the case of employees, male or female, whose labors require 
severe exertion that is trying to nerves, muscles or eyes, or whose occupa- 
tion is sedentary. Even if a half-holiday is granted every Saturday 
throughout the year, the cases of indigestion and nerve-strain resulting 
from insufficient rest and hastily swallowed meals, will make many 
employees chronic sufferers. More harm may thus be done workers 
by an inadequate luncheon period than several years of half-holidays 
will cure; therefore, under none but exceptional circumstances should 
the luncheon period be less than an hour. 

Rest rooms for workers, especially for girls, are an excellent invest- 
ment. An increasingly, large number of factory owners are recognizing 
this fact. Where large numbers of girls are employed, the suffering 
caused by the severe pain of menstrual disorders and by attacks of 
headache or other illness, compel many of them to discontinue work for 
the day. It is not only humane, but economical as well, to provide 
suitable rest rooms where quiet and rest may be obtained by those who 
become ill; frequently, after a rest of one or two hours, a temporary 
indisposition may be relieved and the employee may be able to continue 
work for the rest of the day. 

Many companies have found it profitable, from the standpoint of 
increased efficiency, to allow their employees one or two rest and recre- 
ation periods of from fifteen to twenty minutes each day. These 
periods of rest are particularly valuable when the work is very mono- 
tonous and demands keenness of observation, rapidity of movement 



654 INDUSTRIAL HYGIENE 

or marked physical effort. The quality and quantity of output have 
been greatly improved by allowing such rest periods, to say nothing of 
the improved condition of the worker's health and of the prevention of 
accidents. 

"Speeding Up" and Overtime Work. — The necessity of turning out 
rush orders or of making up for lost time results in great pressure upon 
employees during certain seasons of the year ; this system of stimulating 
intense activity is spoken of as "speeding up." Not only are the 
employees urged on by every means to greater speed during the regular 
working hours but they are also compelled to work overtime. If 
either "speeding up" or overtime work is carried on for an extended 
period of time, or if they are frequently required for short periods, 
they usually cause a severe nervous strain. These strains, which are 
designated "nervous breakdowns" when experienced by people of 
means, often mark the beginning of physical and nervous deterioration 
in the employee and may even permanently impair efficiency. It is 
wisest, therefore, to avoid placing undue strain upon workers and to 
give them ample opportunity for recuperation if signs of nerve-strain 
appear. Moreover, care to prevent the strain due to "speeding up" 
diminishes the employees' liability to accidents, and thus saves him 
from being thrown into the industrial scrap heap and becoming 
dependent upon the charity of the community or of private agencies, 
and it is also a means of conserving to industry an efficient and experi- 
enced worker. The truth of these observations was demonstrated 
strikingly again and again in the recent war, when the women employees 
in the English munition factories were speeded up and made to work 
overtime and Sundays as well; the quantity and the quality of their 
output soon suffered as a result. 

Monotonous and Fatiguing Movements. — Mention has been made 
several times of the effects of monotonous labor; this subject is so impor- 
tant as to merit more extended discussion. When an employee, day 
in and day out, repeats certain prescribed motions of the hands, legs or 
eyes that are limited in character and without variation, the monotony 
induces mental fatigue and overuse of the joints, muscles and nerves 
that may be employed, and may ultimately cause a number of peculiar 
diseases. Examples of these are "telegraphers' and writers' cramp" 
and a variety of local muscular pains, such as those occurring in the 
muscles of the back of the neck in typists, for instance. " Housemaid's 
knee" is a characteristic affection due to overuse of or pressure upon 
the knee-joint. The latter condition is found not only among servants 
but among floor-makers and floor-painters as well. Many other con- 
ditions of a similar character could be cited. While the physical effects 
of monotony and fatigue may manifest themselves in a variety of 
symptoms of local, or special functional abnormalities, the greatest 
importance is to be attached to fatigue as a predisposing cause of more 
or less grave psychic disturbances, or to general diseases such as tuber- 
culosis due to lowered resistance. To remedy such monotony, or such 
excessive strain upon localized nerves, muscle groups, or joints, protec- 



- 



HYGIENE OF ENVIRONMENT 655 

tive measures appropriate to the respective trades should be employed, 
or, employees may be given two or more varied tasks to perform during 
the working day. Thus, to take a rather familiar example, one who 
feeds a packing machine that packs biscuits into boxes, or one who 
feeds a printing press, if assigned, in addition, to some different kind 
of work for a certain number of hours each day, will find the change 
restful and produce a larger output in each department of work. Such 
variety in occupation is especially needed in very large factories where 
there is a tendency to make individuals who are specially adapted to 
certain very restricted and highly specialized tasks, machine-like in 
the character of their work. If diversity in work is not feasible, several 
rest periods should be allowed during the day. 

Physical Strains. — 'When employees perform work which necessitates 
severe muscular exertion, such as lifting weights, they may acquire 
disease of the heart and arteries and other permanent physical dis- 
abilities, or they may aggravate abnormal conditions already exist- 
ing. It is surprising to note how often men are allowed to continue an 
old-fashioned, laborious and clumsy method of doing things, at the 
sacrifice of health and efficiency, merely because it is an old trade 
custom. For instance, men who have to cart heavily loaded wheel- 
barrows or trucks that often weigh several hundred pounds, are com- 
pelled to push their loads over rough cobble-stone roads causing a loss 
of time, strength and efficiency, instead of being provided with hand- 
cars or other vehicles of modern construction that run on smooth 
floors or pavements, or on narrow-gauge rails, to say nothing of elec- 
trically propelled trucks. 

In lifting heavy loads, to cite another example, the dumb-waiter, 
freight elevator and travelling carriage should more frequently be 
employed. Nevertheless, in certain factories in New York City loads 
weighing from three to four hundred pounds are raised to a height of 
two stories or more by means of rope and pulley. Or, again, when 
employees are required to go up and down stairs very frequently during 
the day, whether with or without loads, strain and fatigue are pro- 
duced, especially if they are suffering from a beginning or advanced 
heart or kidney trouble (Fig. 100). The use of freight or passenger 
elevators in such cases makes for efficiency and comfort (Fig. 101). 

Sales people in department stores, motormen, waiters and others, 
who must be on their feet either all or a greater part of the day, fre- 
quently develop swollen or varicose veins of the legs, and flat-foot. 
All these disabling conditions are preventable by the provision of seats 
for use during periods of rest, or throughout the day or dming a large 
part of it. 

Frequently, fatigue and strain of the spinal muscles are produced 
by chairs which have either no backs at all or have improperly con- 
structed ones (Fig. 102). Because of the lack of support for the spine, 
employees assume a constrained posture and may suffer from backache 
and develop curvature of the spine. In work of a character which can 
be better performed if one leans forward somewhat, the best support for 




m, M 




Fig. 100. — An exhausting way of beginning or ending a hard day's work. The energy 
wasted in climbing several nights of stairs hastens fatigue. (Courtesy of Engineering 
Magazine.) 




FlQ. 101. — A way of saving the strength of employees. An elevator adds to the 
efficiency of employees, especially those on upper floors and those who carry heavy 
packages. (Courtesy of Engineering Magazine.) 



HYGIENE OF ENVIRONMENT 



657 



the spine is secured by the use of a chair having a moderately low back, 
which is slightly tilted forward so that the upper end, preferably padded, 
is firmly in contact with the small of the back. If high chairs or stools 
are used, a foot rest will prevent dangling and congestion of the legs, 
and gives comfort. 




Fig. 102. — For continuous work such a stool is very undesirable. The stool without a 
back causes bad posture and rapidly produces fatigue. (Courtesy of Engineering 
Magazine.) 

Alcohol. 1 — There was a time when it was regarded as a good working 
plan to permit employees to drink beer and other alcoholic drinks while 
at work; it was thought to breed good cheer and contentment and to 
secure alacrity in the performance of work. Today every efficiency 
expert and wide-awake business man knows that alcoholic drinks 
taken over an extended period of time, even in small quantities, are 
particularly dangerous if used by workers whose duties require watch- 
fulness and alertness or exposure to heat or physical strain. Dr. 
Moorehead of the Interborough Railroad Company of Xew York, 
reported some time ago an amazing reduction in the number of acci- 
dents among a very large group of men employed in one branch of the 
above transportation system, when they were forbidden to use alcoholic 



1 This section was written before the prohibition of alcohol became a law. 
42 



658 INDUSTRIAL HYGIENE 

drinks at any time under penalty of dismissal. This group was 
contrasted by Dr. Moorehead with another employed in a different 
branch of the system, upon whom no such restriction as to alcoholic 
indulgence had been placed. As already stated the reduction in the 
number of accidents among those who abstained from alcoholic drinks 
was strikingly large. 

However, when men and women are engaged in work in which heat 
and humidity are excessive they will inevitably be tempted to resort 
to alcohol unless water of proper temperature and palatability is freely 
supplied and easily accessible. If the supply of drinking water is 
placed at a distance from employees it will discourage the drinking of 
water because of the effort necessary to obtain it and because of loss 
of time, under such conditions thirst is accompanied by a parched 
throat and a feeling of weakness that makes many a worker welcome the 
relief and apparent stimulus he finds in liquors or other habit-forming 
drugs which give a sense of stimulation. 

The immoderate use of alcohol is most often observed among those 
whose labors are extremely severe or monotonous and unvaried. There 
is a strong craving for something that will bring back animation to 
paralyzed and benumbed faculties. 

When foul odors are constantly present during work, nausea or lack 
of appetite often results; the taste for food is destroyed and women 
as well as men therefore frequently seek to stimulate appetite by taking 
a drink of whisky or beer. This applies with special force to those 
working in fertilizing plants, garbage reduction works, tanneries and 
similar establishments. A parched throat resulting from working in 
an environment in which the fumes of acids, turpentine, benzine, 
naphtha, etc., are present, is another cause for resort to alcoholic 
drinks. 

In America especially, observation has shown beyond any question 
that there is a constantly increasing tendency for the development 
at an early age of diseases of the heart, bloodvessels and kidneys. The 
death-rate from these diseases is steadily and rapidly increasing. One 
of the chief causes of diseases of the heart and kidneys is alcohol. If 
therefore, on humanitarian and economic grounds, we w T ould conserve 
the lives of our workers, our efforts must be bent toward educating them 
to use alcoholic drinks most sparingly, if at all. The growing recogni- 
tion by business men that alcohol and responsibility are incompatible 
will probably do more than any other influence to make for temperate 
use of liquors. 

Warning Workers of Hazards. — As a means of accident and sickness 
prevention, it is perfectly obvious that those who are engaged in work 
that is hazardous should from the very outset be informed by word of 
mouth of the risks they run, and, if they can read, they should be given 
instructions how to guard against such hazards, by signs printed in 
the language they understand best. These signs should be conspicuous 
and placed as near to the points of danger as possible. Signs which 
become covered by dust or dirt are of no value; it is desirable to replace 






HYGIENE OF ENVIRONMENT 659 

warning signs which are familiar and to which workers have become 
indifferent with new ones at frequent intervals, and to change their 
form and wording so that they may excite renewed interest. The 
warning they contain should be reinforced repeatedly by verbal instruc- 
tion, so as to refresh the minds of the employees and prevent their 
becoming indifferent. 

In connection with all sanitary improvements and safeguards which 
are installed, which employees are likely to misuse or to ignore, the 
infliction of penalties by the denial of special privileges, or even by 
dismissal, if employees are deliberately careless and thereby imperil 
their own lives and those of others, may, at the outset, be absolutely 
essential to maintain discipline and to keep down the accident and 
sickness rate. 

In factories in which especially hazardous trades are carried on, only 
the very poorest type of unskilled employee can, as a rule, be obtained. 
Even unskilled, newly arrived immigrants cannot be induced to stay 
long in certain very hazardous trades. They abandon such employ- 
ment at the very first opportunity, and, especially, if the wages are 
low. There is, as a rule, difficulty in filling the places left vacant by 
such men, and employers therefore often dare not enforce discipline. 
When foreigners are exposed to particular hazards, competent inter- 
preters ought to be secured to explain the dangers to which the men 
are exposed, as well as the methods for their prevention. In addition 
to this, and of even greater importance, is the installation of every 
reasonable device that will add to the attractiveness and safety of the 
employment. 

It is difficult to understand why any employer who is engaged in 
work which is not of a temporary character, and which he hopes to 
continue for years, should hold back from installing modern and 
humanitarian methods of work. Only the business man who intends 
to make a one-night stand can logically object to installing the most 
efficient and health-conserving devices. An established business would 
seem logically to demand equipment and methods that will tend to 
promote the highest efficiency, and such efficiency is in the last analysis 
dependent upon the worker who is kept in the best possible form physi- 
cally, and whose skill and experience are conserved for the good of the 
establishment by foresight and a liberal policy. 

In connection with safety measures, much that has already been said 
in discussing the subjects of strains, dust, lighting, ventilation, etc., 
could profitably be repeated here. Indeed, if the topic were to be dealt 
with as its importance merits, it would be necessary to greatly amplify 
much that has previously been said. All that can be done in a brief 
sanitary guide of this character is to mention certain additional features 
of importance. Besides, since the enactment of the Compensation 
Laws, safety devices and methods have received so much attention 
at the hands of various writers that it has been sought to focus atten- 
tion upon the subject of disease prevention, which, relatively speaking, 
has scarcely received the notice it merits. 



GUI) 



INDUSTRIAL HYGIENE 



Instructions in Safety Methods and First-aid. — Every employee 
should be given careful instruction so that he may thoroughly under- 
stand the machines at which he works, the care of tools, furniture and 
equipment, the peculiar or special hazards of his environment, and 
the accidents which may result from carelessness. For this purpose 
employees should be formed into committees under the guidance of 
expert instructors and supervisors, to instruct their fellow-workers in 
safety methods, to act as a sort of a police to warn against carelessness, 
and report instances of it to those in charge, if necessary, and, finally, 
to make recommendations as to improvements and new devices for 
preventing accidents. 

A number of foremen and other employees should be carefully taught 
to administer first aid to injured employees; competence in first aid 
methods should be acquired by as many as possible. The instruction 
given in this work should lay special emphasis upon the application of 
methods for combating shock, whether from hemorrhage, electric 
currents or violent injury. The men should be taught also to employ 
artificial respiration, and how to prevent the soiling of open wounds 
pending the arrival of a physician. 




Fig. 103 



A clean space or room, so situated as to be easy of access and as far 
as possible removed from noise and dust, should be set aside for the 
care of emergency cases. If such a room is not available one can be 
improvised as follows: A rod of thin iron piping, eight feet long, 
should be fastened horizontally in the wall at one end, at about six feet 
above the level of the floor, the free end reaching a corner of the room 
and the fixed end being fastened to the wall by a hinge arrangement 
which allows it to swing outward. Another pipe or rod should be 
similarly placed and fastened to the adjacent wall (Fig. 103). 

From each rod is hung a white curtain, eight feet wide and reaching 



HYGIENE OF ENVIRONMENT 661 

to the floor. When it is desired to convert the corner space into an 

emergency room each curtain is swung outward at a right angle to the 
wall to which it is attached, thus forming an enclosure eight feet square. 
For economy of space a metal cot may be fastened on hinges to the wall 
covered by one of these curtains and turned up flat against the wall and 
secured in this position by a strap. When needed the cot can be 
unstrapped and allowed to swing downward. Surgical tables can be 
formed from metal or wooden plates on hinges fastened to the wall. 
The entire arrangement, although one that is not free from criticism. 
is a compact and useful one where a better arrangement is impossible. 

Safety Devices. — Belting. — Belting on machinery should not be 
under too great tension. The ends of belting should be smoothly 
spliced, laced or glued; loose or torn ends should never be allowed to 
whirl around. Belting, if it runs within seven feet from the floor, 
should be guarded by sheet metal, wood, wire-mesh or railings. 
Mechanical belt-shifters should be installed; hand-shifting of belts 
should not be permitted, neither should any repairs on machinery be 
undertaken while it is in motion. 

Guards. — Guards should be placed not only about belting but also 
about pulleys, gears, shafting, and all cutting, punching or sawing 
machines, if these are within the reach of employees working on floors 
or platforms. These guards should be removable for repair or inspec- 
tion, but this should never be done while the machines are in motion. 
Also, special measures or devices should be employed to prevent the 
starting of machinery while it is being overhauled or examined. 

Goggles and Respirators.— Strong and well-made goggles and respira- 
tors should be furnished to those whose work exposes them to flying 
fragments and to dust in the process of chipping, sand-blasting, grind- 
ing or polishing of stone, marble, metal or glass. Likewise, goggles 
should be worn by those who handle molten metal or who are exposed 
to blinding electric flashes. Foreign bodies which have entered the 
eyes of employees should be removed only by one who is trained to the 
work and surgically clean; all other eye injuries should be treated only 
by the medical attendant who is connected with the establishment or 
by a specialist or other physician if there is no regular medical attendant 
in the factory. Serious diseases and even loss of sight have frequently 
resulted from the attempts of fellow-workers to remove foreign bodies 
from the eyes of workers, or from effort to care for other forms of injuries 
to the eyes. 

Protective Clothing. — Loose or torn clothing should not be worn by 
those who work near revolving or moving belting, gears or other moving 
parts of machinery; in order to prevent their hair from being caught 
in such parts girls should wear caps. Men who handle molten metal 
should wear substantial and well-fitting shoes without laces. (In some 
of the best factories asbestos covered shoes, gloves and clothing are 
used. When dangerous chemicals are used, the hands and the exposed 
parts of the arms should be covered with gloves made of impervious 
material and kept in good repair. 



662 INDUSTRIAL HYGIENE 

Emery Wheels and Grindstones. — Emery wheels and grindstones 
should be frequently inspected in order to discover cracks and other 
imperfections. They should be carefully and firmly mounted, and 
centered without the use of wooden wedges which may expand when 
wet, or be driven in too vigorously, thus causing the stone to crack. 
Strong hoods connected with an exhaust fan should be adjusted to 
wheels so as to serve the double purpose of protecting the worker from 
accidental breaking off of a part of a stone wheel while in revolution, 
and also to remove dust arising in the process of grinding. 

Dangerous Chemicals, Acids, Caustics, etc. — Chemical substances 
should be carefully stored and guarded so that fumes or dust arising 
from them may be properly disposed of or prevented. All open vats 
of chemicals should be guarded by substantial railings to prevent 
employees falling in. Platforms and walks situated over and around 
such vats should also be carefully railed in. Xo employee should be 
allowed to work alone in a room where dangerous chemicals are stored 
or used, because if a worker should be overcome, in the event of an 
accident, another should be close by to render aid. In such establish- 
ments as many as possible should receive instruction in first-aid treat- 
ment and have at hand the appropriate antidotes against the specific 
poisons that are employ ed. Labels should be attached to all containers 
of poisonous chemicals, and on each should appear a warning as to 
careful handling, and instructions as to the use 01 the proper antidote. 

Hoisting Machinery and Elevators. — Hoisting cranes should be well 
guarded, and where traveling cranes are employed they should be 
protected with fenders, gongs and brushes to give warning of their 
approach. Objects to be moved on cranes should be securely placed 
or fastened so that they will not fall upon persons passing underneath, 
and workers should be warned against passing underneath moving 
cranes. All parts should be frequently inspected and kept in good 
repair. 

Elevators should at all times be in charge of responsible and exper- 
ienced operators, and no other persons should be allowed to run them. 
Efficient locks to prevent the sudden starting of cars must be provided. 
Doors and gates should be strongly constructed, kept in good repair, 
and be furnished with effective locks. Where hatches are used, the 
doors should be made strong and no one should be permitted to walk 
upon them, and strong railings should be placed about them. All 
cables and safety devices should be frequently inspected. Men who 
run elevators should, if possible, be provided with a folding seat. 
Constant standing causes fatigue and tends to increase the liability 
to accident and the development of flat-foot. 

Ladders. — Too frequently ladders, sometimes of the flimsiest con- 
struction, are employed, when it would be not only practicable, but 
economical and safer as well, to build stairways. When ladders are 
necessary they should be strongly built, preferably of iron, and with 
hand-rails or other guards to prevent falls. When in use ladders should 
be firmly secured at the top and at the bottom, and the upper end 



HYGIENE OF ENVIRONMENT 



663 



should project at least four feet above the platform or landing to 
which it leads (Fig. 104). 




Fig. 104.— Enclosed ladder to prevent falls. (Courtesy of U. S. Steel Corporation.) 



Nails. — Nails, especially rusty ones, should always be removed from 
floors, boards or planks from which they protrude, so that they may not 
cause injuries and infection to those accidentally stepping upon them. 

First-aid Kits. — First-aid kits should be dust-proof and made of 
metal, or of metal and glass. They should be attached to the wall of a 
clean emergency room which is as free from noise as possible, and which 
gives complete privacy. Such a room should be readily accessible, 
and if the establishment consists of a number of floors a stretcher for 
carrying injured persons should be available on each floor. Additional 
first-aid kits and emergency rooms should be provided when a factory 
occupies several buildings. The quantity and character of the supplies 
of a first-aid kit must of necessity vary with the size of a factory and 
with the type of injury or accident peculiar to a particular industry. 
In New York State the law requires that the kit should contain the 
following articles: 



664 INDUSTRIAL HYGIENE 

Instruments: 
1 pair of scissors. 
1 thumb forceps. 
1 tourniquet (to stop hemorrhage). 

1 graduated medicine glass. 
Medicines: 

2 ounces of aromatic spirits of ammonia. 

2 ounces of 4 per cent, boric acid solution. 

2 ounces of alcoholic solution of iodin (tincture of iodin) for 

external use. 
2 ounces of castor oil (for eye injuries). 

2 collapsible tubes of bicarbonate of soda, 3 per cent., each tube 

3 ounces, for burns). 
1 pint of tincture of green soap. 
Dressings : 

1 dozen assorted sizes of sterile gauze bandages. 

1 spool of Z. 0. adhesive plaster. 

3 packages of absorbent cotton, \ pound each. 
3 packages of sterile gauze, 1 yard each. 

Splints, assorted sizes. 

Wooden applicators wound with cotton. 

Wooden tongue depressors. 

Stretcher (if factory consists of more than one floor). 

2 chairs. 

1 small table. 

Washing facilities consisting of : water, soap, basin and towels. 

Fire Hazards. — Fire hazards are being guarded against with increas- 
ing vigilance, owing to the stringency of the laws on this subject and 
the keen public sentiment which has been aroused by several terrible 
tragedies which have resulted from lack of fire-prevention methods and 
devices. The newspapers in particular have been alert and active 
in reawakening public opinion every time loss of life has occurred from 
this cause. 

Constant watchfulness must be exercised in order to prevent smoking 
in factories and the careless lighting of matches where inflammable 
materials are handled; the example of a person in charge of an estab- 
lishment smoking during working hours is pernicious. Rubbish heaps 
should not be allowed to accumulate, and metallic or metal-lined 
receptacles should be provided for excelsior, shavings, waste paper and 
cloth, sweepings and other materials that easily ignite. Explosive 
and volatile or inflammable chemicals should be carefully stored out- 
side the main building, and they should be handled with extreme care 
and not brought near flames or lights. Electric wiring should be care- 
fully insulated and frequently inspected. 

Doors should open outward and should be unlocked during working 
hours. Fire escapes should be adequate in size and number and of 
substantial construction; they should have wide balconies and stair- 
ways and be free from obstructions. 






MEDICAL SUPERVISION 665 

(ias lights should be guarded by wire globes. Sprinkler systems, 
hose pipes and fire extinguishers should be freely provided. Sawdust 
in fire-proof containers and pails filled with water should be kept ready 
for emergencies. 

Above all things factory buildings should be of fire-proof construction 
throughout, especially if they are more than four stories in height, or if 
large numbers are employed on the respective floors, or if the mate- 
rials manufactured or handled are inflammable. Stairways should be 
interrupted -by broad landings at each floor, and should be of a width 
proportioned to the number employed in the building. The stair wells 
should have a fire-proof enclosure. Fire-proof hand rails should be 
placed on one or both sides of the stairways, and if the latter are very 
wide an additional rail should run down the center. The treads should 
be of the non-slip variety and kept in good repair in order to prevent 
persons from falling or slipping on irregularities or holes. 

Fire drills should be frequently conducted and thorough in character. 
The role or duty of each individual should be definitely established. 
Drills should be ordered at unexpected times in order to accustom 
employees to the atmosphere of excitement such drills ordinarily create 
and to prevent panics. 

MEDTCAL SUPERVISION. 

The employment of nurses for full-time duty in a factory has become 
so familiar, and the value of their services has been so generally acknow- 
ledged by employers and managers under whom they have worked, that 
no special pleading should be required to secure a wider recognition of 
their usefulness in the industrial sphere. Experience in the working 
out of Compensation Laws has given the most convincing proof that 
the factory physician who is interested on' behalf of the company in 
giving the best surgical care to those of its employees who are injured, 
can save his employers a great deal of money, obviate lawsuits and 
rapidly restore skilled workers to usefulness. In addition the physician 
should be competent to maintain supervision over the health of 
employees and suggest measures to prevent accidents and disease. 
Too often, unfortunately, the range of the physician's activities and 
his responsibilities are so narrowed that the benefits in increased effi- 
ciency and health which might otherwise be enjoyed by the worker 
and the employer are very much diminished. Sometimes, the fault 
lies with the physician, ivho regards his connection with the factory merely 
as a means of adding to his income and is therefore not sufficiently informed 
as to the details of factory hygiene and sanitation. More often it is due 
to the fact that the physician is hampered in the performance of his super- 
visory work, or is not consulted by foremen and superintendents in matters 
of which he is the best judge. 

There are as yet in this country but a handful of physicians who are 
competent and willing to study factory processes, the environment of 
the workers and the diseases and accidents to which the latter are 



000 INDUSTRIAL HYGIENE 

especially subject from the point of view of prevention. A physician 
who is attached to a factory in which diseases of a certain type are 
common is unworthy of his place if he fails to make a study of all 
factory conditions in order to prevent or check the occurrence of such 
diseases. 

Accident and sickness prevention w T ill never be thoroughly effective 
until companies employ a physician who will do more than establish a 
factory dispensary. The average general dispensary gives poor service, 
but the store or factory dispensary is, as a rule, the poorest of them all. 
The ideal factory physician is he who is competent to go through the 
plant and act as an adviser to the owner of a business on matters 
relating to sanitary engineering and to give competent advice regarding 
construction and equipment and their effects upon health. He should 
frequently inspect and reinspect the factory premises and the working 
conditions, so that he may be able to discover defects in sanitation and 
suggest corrections of w T rong methods of work and faulty habits of em- 
ployees. Such a physician should not be made subordinate to the fore- 
men or supervisors, but should be made a member of the official staff, 
with specified duties and recognized authority. First aid and emergency 
service are indeed important, but they are by no means all that the 
physician should be required to render; his work should never be 
allowed to degenerate into wholesale dispensary service which gives 
no more than an opportunity to glance at a patient. The :r-ray, the 
stomach-tube the microscope and all the other essentials for correct 
diagnosis and treatment must, as a rule, and of necessity, be lacking 
in the factory dispensary; it is therefore important in the absence of 
good night clinics in any community that employees who cannot afford 
to pay a private physician should be given leave to absent themselves 
from w r ork during the day without loss of pay; this will enable them to 
attend a reputable day clinic or hospital for medical care. Under such 
a system, workers suffering from tuberculosis, cancer, diabetes, ulcer 
of the stomach, kidney and heart diseases, etc., will be enabled to 
receive early care of such nature that their lives may be lengthened 
and their health and comfort safeguarded. In the case of diseases 
which are amenable to treatment when promptly recognized, this 
system may also mean the restoration to health and activity of many 
who might otherwise become hopelessly ill or disabled. 

The preliminary medical examination of all applicants for work 
frequently brings to light signs of a beginning or advanced disease of 
the heart, lungs, kidneys, eyes, ears or of other organs, which may 
predispose the applicant to the occurrence of accidents or cause pre- 
mature death. . Periodic medical examination of all employees exposed 
to occupational hazards is undoubtedly of the greatest preventive 
value. 

There are many small industrial establishments the owners of which 
recognize the value of the industrial physician and nurse, but find the 
cost of their services too great to bear unaided. There is no reason 
why a number of such small establishments situated in one building, or 



MEDICAL SUPERVISION 667 

in a restricted locality or zone, or having common trade interests, 
should not unite to secure medical assistance through a central medical 
service station, by dividing the cost. 

Finally, the physician and nurse should be required to keep careful 
records of all cases of sickness or accident arising during the course of 
the year, whether these are cared for by the industrial nurse or physi- 
cian or by private agencies. Such a record would be of value not only 
in showing the extent and worth of the physician's or nurse's work but 
would also indicate the departments or processes which are particu- 
larly dangerous and thus suggest the need for special remedies. Thus, 
if a large number of "colds" were traced to a special department, or 
if pneumonia, tuberculosis, rheumatism, skin diseases or "flat-foot" 
were found to be prevalent among a particular group of employees, a 
search for the special cause of the undue frequency of any of these 
conditions would naturally suggest itself. The nurse, in addition to 
her special ministrations to sick or injured employees, should also 
acquaint herself with home conditions and domestic habits that may 
be undermining the health of workers, and when these are ascertained, 
she may, by persuasion and friendly visits of instruction, seek to assist 
in eliminating certain causes of physical impairment or disability by 
giving advice as to diet, ventilation, the proper use of sleeping quarters, 
etc. 



CHAPTER XXV. 

CHILD HYGIENE. 

By S. JOSEPHINE BAKER, M.D., D.P.H. 

Child hygiene is a broad term which is used to designate all matters 
which pertain to the physical well-being of children before the period 
of adolescence. This age group has been used as a unit in public health 
activities because of the recognition of several factors: (1) According 
to the census of 1910 one out of every five deaths at all ages occurs 
under the age of one year and one out of every three deaths at all ages 
occurs under the age of five years. (2) Ninety-five per cent, of the cases 
of contagious diseases occur under the age of fifteen years, while 90 
per cent, occur under the age of five years. (3) Preventive health 
work for the individual is most effective when it deals with an age group 
which is in process of growth. Health habits, as well as health itself, 
can be established in the period of childhood more certainly than after 
growth has taken place. 

In order to be fully effective, child hygiene work must be inclusive 
of all activities and environmental conditions that in any way affect 
child life from the prenatal period to puberty. For this reason the 
State and municipal health authorities have established bureaus or 
divisions of child hygiene. New York City established the first bureau 
of this kind in 1908. Since then, thirty State divisions have been 
established. 

Federal recognition of the importance of this work was accorded on 
April 9, 1912, by the establishment of the Federal Children's Bureau 
under the United States Department of Labor. Practically every city 
of importance in the United States has a division or bureau of child 
hygiene and they are almost equally common to small communities. 

Organization. — The organization of a bureau of child hygiene must 
depend largely upon the appropriation available and whether the work 
is to be done in an urban or a rural community. It must be recog- 
nized that preventive health work for children has grown to be a definite 
specialty and people assigned to such duty should not, unless the exi- 
gencies of the rural service demand such action, be assigned to any 
duty other than that pertaining to the care of infants and young 
children. The effective results that have been attained in certain 
American cities have occurred where this program of specialization has 
been carried out. In other cities where physicians and nurses were 
assigned to various duties including child hygiene, the results have been 
distinctly less satisfactory. 

There should be a physician in charge of this bureau. While 
administrative ability is of first importance and may be considered 



FUNCTIONS 669 

absolutely essential, the background afforded by a medical education 
preferably followed by education in public health, is necessary for a 
person who must outline the policy, prepare the program and be re- 
sponsible for results in child hygiene work. Under this director or chief, 
who should be a full-time employee, may logically be placed various 
chiefs of divisions and a superintendent of nurses. In small towns 
such added officials will be unnecessary; in cities, owing to the rapid 
growth of this work and the extension of its activities, this further 
specialization seems essential. Supervising inspectors and supervising 
nurses, responsible to the chiefs of divisions and the superintendent 
of nurses, should have immediate control of the field force. The 
essential clerical force is, of course, implied. In small towns or rural 
communities, the organization must be adapted to the circumstances. 
Functions. — The functions of a well-organized bureau of child hygiene 
should include: 

1. Regulation and standardization of obstetrical procedure by: 
(a) Education, licensing and control of midwives. 

(6) Supervision of standards of lying-in hospitals. 
(c) Provision for maternity nursing. 

2. Prenatal work, including: 

(a) Establishment of prenatal or maternity centers. 

(b) Supervision and instruction of expectant mothers. 

(c) Essential legislation for protection of women of child-bearing 
age or pregnant women in industry. 

3. Reduction of infant mortality by: 

(a) Measures outlined under (1) and (2). 

(6) Instruction of all mothers of children under one year of age with 
necessary health supervision of such infants. 

(c) Readjustments of social, economic and environmental conditions. 

(d) Education of young girls in personal hygiene and in the care of 
infants. 

4. Health supervision of children of pre-school age by: 
(a) Maintenance and supervision of day nurseries. 

(6) Supervision and control of institutions caring for dependent and 
delinquent children. 

(c) Health examinations and follow-up of children of pre-school age. 

5. School medical inspection by: 

(a) Health supervision of all children of school age. 

(b) Establishment and maintenance of standards for school hygiene. 

(c) Establishment or supervision of adequate facilities for the treat- 
ment of defects or illnesses of children. 

6. Child labor. 

(a) Establishment of legal standards controlling the employment of 
children. 

(b) Supervision of children under sixteen years of age engaged in 
industry. 

(c) Establishment of health standards essential for the issuance of 
employment certificates. 



670 CHILD HYGIENE 



CONTROL AND SUPERVISION OF MIDWIVES. 

The relation of the employment of midwives to the mortality or 
morbidity of childhood varies in different parts of the country, depen- 
dent upon the extent of the employment of these women. In certain 
western States midwives take care of as high as 75 percent, of confine- 
ments. This practice is particularly common in some rural communi- 
ties where either professional midwives or women neighbors attend a 
large proportion of the births. Studies as to the extent of this practice 
and the lack of care at time of confinement have been made by the 
Federal Children's Bureau. In the east, legislation regarding the 
practice of midwifery shows great variations. In certain States, 
the practice of midwifery by other than regularly qualified physicians 
is prohibited, yet a number of midwives continue to take care of women 
at confinement and even report the births. The attitude of health 
authorities toward midwives varies. Some States completely ignore 
them, some have legislated against their right to practice, some have 
established standards of practice, while others have required some 
preliminary education. New York City requires a six months' educa- 
tion at a school for midwives under municipal control. 

The practice of midwifery in Europe is well regulated. England 
requires a six months' preliminary training while all other countries 
require courses of training varying from one to two years. After 
graduation, these midwives are all under government control and sub- 
ject to stringent regulations. The possibilities of harm resulting to 
the mother or child owing to lack of care at time of confinement are 
so obvious that no other argument would seem necessary for the 
supervision of midwives. 

In such supervision the following points should be insisted upon: 

1. Registration and licensing of all women found competent to 
practice midwifery. This licensing should be based upon : 

(a) Adequate preliminary education and training of at least six 
months in a properly supervised midwifery school. 

(6) Moral character and good personal habits. 

(c) Strict adherence to the regulations covering the practice of 
midwifery. 

2. Supervision of midwives. After the midwives have been licensed 
they should be : 

(a) Under active supervision by physicians or visiting nurses. 

(b) Regularly instructed individually and in classes as to proper 
methods of procedure. 

Ophthalmia Neonatorum. — Physicians and midwives should be 
required to report every case of sore eyes occurring in their practice 
in a baby under ten days of age. Each such case should be visited 
by a physician and, if discharge is present, a smear should be taken 
to determine the presence of the gonococcus. Such children should 
be referred immediately for treatment to a physician or hospital and 



INFANT MORTALITY 671 

the case should be kept under observation by the visiting nurse to see 
that such treatment is received. 

In case of positive diagnosis of gonorrheal ophthalmia, close super- 
vision should be maintained over each case and in no instance should 
the case be discharged from supervision until it has been terminated so 
that the final results may be known. Use of the silver nitrate solution 
in the eyes of newborn babies should be required of midwives and 
urged upon physicians. It has been found in public health practice 
that the required use of this prophylactic will decrease the number 
of cases of ophthalmia neonatorum to a minimum and that the early 
recognition of these cases, with subsequent adequate treatment, has 
practically eliminated blindness as a result of this disease. 

Puerperal Septicemia. — Deaths of women due to accidents or diseases 
of childbirth have been steadily on the increase in the United States. 
It is estimated by the Federal Children's Bureau that in the age group 
from twenty to forty-five years of age diseases and accidents of childbirth 
furnish more deaths of women than any other tabulated cause of death 
except tuberculosis. In a recent bulletin issued by the Children's Bureau 
of the United States Department of Labor, in a discussion of maternal 
mortality, Dr. Grace L. Meigs states as follows: "Mortality figures 
do not show a decrease in the death-rates from childbirth in the larger 
cities in recent years. The death-rates of the whole group of cities 
of eight thousand or more inhabitants in the registration States for the 
years 1900 and 1913 show no decline. The rate in 1900 was 14.9 and 
in 1913 17.2. The death-rates from childbirth for the same period in 
a group of seven large cities have been studied; the rates from Xew 
York City alone show a definite and steady decline. In 1905 the rate 
per 100,000 inhabitants was 20.3, in 1913*14.1." 

The reporting by physicians and midwives of every case of puerperal 
sepsis should be insisted upon and in each instance investigation should 
be made to determine whether or not the disease was the result of 
criminal interference or carelessness. The revocation of licenses and 
the prosecution of midwives, as well as prosecution of physicians, for 
negligence in this direction, has a deterrent effect and is a justifiable 
procedure for the reduction in the number of cases of this disease. 

INFANT MORTALITY. 

As prenatal work is distinctly a part of the campaign to reduce 
infant mortality, it will be considered under this section. Infant 
mortality is the number of deaths of infants under one year of age 
per thousand living births occurring in the same area in any one 
calendar year (Eastman). This standard has been decided upon as 
providing the most accurate information obtainable in various locali- 
ties. Strictly speaking, infant mortality should be based not upon the 
number of living births in any one calendar year but upon the exact 
ratio of the number of children born and who live to pass their first 
birthday, irrespective of the year in which they were born. Such 



072 CHILD HYGIENE 

statistics, however, are readily obtainable only in institutions where 
babies are born and are kept during their first year. In cities or even 
in smaller communities, such data would be difficult to obtain. For 
purposes of accurate statistical data, however, it may be obtained, 
for part of a community, as for instance in studies made by the chil- 
dren's bureau where the births for a certain year are tabulated and each 
case is followed up. In cities, owing to the migratory habits of so large 
a proportion of the population, this method has been found to be 
practically impossible. A survey undertaken in New York City of 
two thousand births for the purpose of following them up for a period 
of five years had to be abandoned because at the end of the first year 
over 30 per cent, of the families had moved without leaving any address 
and at the end of the second year over 50 per cent, of the remainder 
could not be found. Adult mortality is usually based upon the esti- 
mated population. The method, therefore, of recording infant mor- 
tality as given above has the advantages of (a) practical accuracy, 
(6) standardization so that it is comparable with the infant death- 
rates of other communities. 

The Problem of Infant Mortality. — Waste of life at its beginning 
is essentially a public health problem. As will be seen later, the causes 
of infant mortality are so complex and in general so closely related 
to community life and environment that the individual, unaided, has 
little opportunity to combat it. While the efforts to control infant 
mortality are mainly directed to the education of the mother, it is 
important that the community provide for the necessary social, 
economic and hygienic aids for the mother to use. For the past fifty 
years the general death-rate has shown a marked and steady decrease 
in all civilized countries. The infant mortality-rate has also shown a 
decrease but not as marked as that of the general rate. Owing to the 
meager statistical data available in the United States reference will 
have to be made to Europe in this regard. Table I, showing the birth- 
rate per thousand of the population, the death-rate per thousand of the 
population and the infant mortality per thousand of the population 
in England and Wales for ten-year periods from 1851 to 1905 illustrates 
this tendency. It also shows the striking reduction of the birth-rate, 
a reduction which is common to the countries of Europe but which 
has not yet shown itself in the United States. 

TABLE I. — ENGLAND AND 

Birth-rate per 
1000 population. 

1851 to 1860 34.1 

1861 to 1870 35.2 

1871 to 1880 35.4 

1881 to 1890 32.5 

1891 to 1900 29.9 

1901 to 1905 28.4 

1 From 1832 to 1850 the average infant mortality in England and Wales was 153. 



1 VVAljIiD. 

Death-rate per 
1000 population. 


Infant death-rate 

per 1000 

population. 


22.2 




154 1 


22.5 




154 


21.4 




149 


19.1 




142 


18.2 




154 


16.0 




138 



INFANT MORTALITY 673 

The reduction that has already taken place in infant mortality is 
due very largely to improved environmental conditions. The infant 
is acutely sensitive to its environment. It has become a trite but 
none the less true statement that infant mortality is the most sensitive 
index we have of the sanitary condition of any community. The 
fact, therefore, of general improvement in health conditions and in 
sanitation has been reflected in a general reduction in the infant 
mortality-rate. This reduction, however, has not kept pace with the 
reduction in the general death-rate and it has become apparent that if 
this waste of life is to be stopped, the reduction in the death-rate of 
infancy must be considered by itself and have individual and intensive 
methods applied to it. 

There is no part of life where the death-rate is so high as under one 
year but, correspondingly, there is no part of life where reduction of 
the death-rate offers fewer difficulties. The distribution of the infant 
death-rate by months has a marked bearing upon the methods taken 
to reduce it and the degree in which it may be considered preventable. 
In the registration area of the United States in 1910, 154,373 deaths 
occurred under one year of age, with a death-rate of 15.95 under one 
year based upon one thousand estimated infant population under 
one year. The ages at which these children died are shown in Table II. 



Died during first day of life 

Died during first week of life 

Died during first month of life 

Died during first three months of life 

Died during first six months of life . 116,039 0.75 

This table is of interest as a comparison with one made by Farr of 
England in 1864 in his report as Registrar-General : 

TABLE III — DEATH-KATE BY MONTHS OF INFANTS IN ENGLAND AND 

WALES 1851 TO 1860. 

Age in months. Boys. Girls. Total. - 

Otol 64.50 49.45 57.13 

1 24.09 19.50 21.83 

2 17.18 14.19 15.71 

3 14.42 11.91 13.18 

4 13.86 11.30 12.60 

5 13.29 10.76 12.05 

6 12.71 10.27 11.50 

7 12.11 9.84 10.99 

8 11.50 9.48 10.50 

9 10.86 9.18 10.03 

10 10.22 8.93 9.58 

11 , . 9.56 8.75 9.16 

While this waste of life in infancy is deplorable at any time, it 
becomes a menace to the future integrity of the country if long con- 
tinued and particularly if taken in connection with the falling birth- 
rate. This is particularly true in time of war where the mortality in 
43 



TABLE II. 








No. 


Per cent. 




14,946 


0.10 




36,351 


0.24 




58,089 


0.38 


s of life 


86,235 


0.56 



674 CHILD HYGIENE 

the adult group is apt to be excessive and where the future welfare 
of the country must depend entirely upon the virility of the next 
generation. During the past World War it was estimated by the 
Registrar-General of England — Sir Bernard Mallett — that the reduc- 
tion in the birth-rate during the first three years of the war among 
European belligerents amounted to a loss of over 650,000 potential 
lives in England, over two million potential lives in Germany and 
1,000,000 in Austria-Hungary. He stated that the total reduction 
in the birth-rate in all European countries at war had, in the first 
three years of the war amounted to a potential loss of life in excess of 
12,500,000 and that the war is causing a reduction in the birth-rate 
equivalent to the loss of seven thousand lives per day. 

Causes of Infant Mortality. — The causes of infant mortality are 
complex and inclusive of all factors which in any way concern the 
health of an individual. These factors bear most heavily upon infancy 
because the infant is more acutely sensitive to his surroundings than 
any other age period. This sensitiveness decreases in proportion to the 
age of the child and after adult life is reached it remains stationary 
and limited in degree. The causative factors tend to blend into each 
other or to overlap. A sharp separation is difficult but, in general, 
they may be considered under two headings: (1) Environmental, 
including all matters pertaining to the general hygiene and sanitation 
of the community and to economic and social factors and (2) medical, 
including the actual contracting of disease. 

Sanitary, Hygienic, Social and Economic Causes of Infant Mortality. — 
Fundamentally, infant mortality may be said to be caused by two 
factors — poverty and ignorance. Further analysis, however, should 
be made. The environmental conditions may be classified as (a) 
social, (b) economic, (c) racial and {d) general environment. 

It is difficult to show the exact statistical relation between the 
general sanitation of a community and the infant death-rate but that 
this relation exists may be proved by a consideration of the fall in the 
infant death-rate concomitant with that in the general death-rate, due 
to improved sanitary conditions. Clean streets, improved housing 
facilities, opportunities for fresh air and a supply of pure water, are 
all general conditions which have their effect upon the reduction of the 
infant mortality even more surely than they have upon the adult 
mortality. 

Overcrowding. — Certain more intimate unhygienic conditions, how- 
ever, bear directly upon the infant morbidity and mortality-rates. 
Density of population in any given acreage does not in itself bear a 
direct relation to the infant death-rate. The number of people in a 
given area may cause conditions of overcrowding, if the buildings are 
limited in height, whereas there may be no such overcrowding in 
buildings covering the same acreage but which comprise many more 
floors. The true effect of overcrowding upon infant mortality relates 
to the density of population in rooms rather than ground space. 
'Faking it from this point of view, it has been shown definitely in studies 






INFANT MORTALITY 075 

made by Newman, of England, that in a group of families studied the 
death-rate was as follows: 

Infant death-rate. 

Those living in one room 219 

Those living in two rooms 157 

Those living in three rooms 141 

Those living in four or more rooms 99 

It was also found that the infant death-rate was twice as great with 
five people living in a room as with two living in a room. The infant 
mortality-rate in connection with the number of people living in a 
room is affected by the related factors which include lack of proper 
ventilation and neglect of personal hygiene. Such conditions have a 
marked influence upon the occurrence of contagious diseases, particu- 
larly measles and the respiratory diseases in young infants. 

Unhygienic Conditions. — The actual relation of cleanliness or filth in 
living apartments is shown graphically by the report of conditions in 
Johnstown, Pa., where the infant death-rate was found to be as follows: 

Clean rooms 113.5 

Dirty rooms 1S6. 

The type of home lived in also had its effect, irrespective of cleanli- 
ness. This is shown clearly by the amount expended for rent. The 
index that was adopted in this case was whether or not water was 
piped into the house and whether or not there was a bathtub in the 
house. It must be understood that the relation of the water or the 
bathtub can in this instance be considered nothing more than an index 
to the social status of the family and their presumptive poverty and 
manner of living. The infant death-rate under such conditions was 
found to be as follows : 

Water piped into house 117.6 

Water carried into house from outside 197.9 

Bathtub in house 72 . 6 

No bathtub in house 16-4.8 

Immigration. — The influence of the influx of alien races upon infant 
mortality must include a consideration of delay in adapting methods 
of living to the new environment, as well as ignorance and poverty. 
The city statistics of Xew York City made by Guilfoy show that out 
of every thousand infants born to mothers of Russian-Polish or Austro- 
Hungarian nationality, over 920 survive the first year of life. Of 
infants born to Italian mothers, 897, of native mothers, 894, German 
mothers 885 and Irish mothers 881 survive this trying period of exist- 
ence. Other significant results of this analysis show that of all deaths 
from congenital diseases under one year of age per ten thousand births 
reported, the nationality of the mother seems to be a dominating 
factor. The death-rate from these causes in children born of Italian 
mothers was 295, Russian-Polish 320, Austro-Hungarian 284, native 
544. This striking analysis has a marked relation to the causative 
factors involved in the deaths from congenital diseases and clearly 



676 CHILD HYGIENE 

indicates that the method of approach in the future must take into 
consideration more than it has in the past the high death-rate of children 
of native parentage. 

The effect of nationality upon deaths from infectious diseases shows 
that children of Italian mothers show the highest mortality from this 
group of diseases, with a rate of 58. The children of Irish mothers 
rank next, with a rate of 57, children of native mothers 38, children of 
Austro-Hungarian mothers 36. 

In acute respiratory diseases race seems to play a very marked part. 
The death-rate of babies of Italian mothers from respiratory diseases 
is "more than three and a half times that of children of German 
mothers, almost three times that of children of Russian, Austro- 
Hungarian and Irish mothers and a little more than double that of 
American mothers." 

In the mortality from diarrheal diseases, the racial aspect is shown 
as follows: Children of English parents 91 per ten thousand, children 
of native parents 80 per ten thousand, children of Irish mothers 72 ' 
per ten thousand, children of Italian mothers 70 per ten thousand, 
children of Austro-Hungarian mothers 52 per ten thousand and 
children of Russian mothers 30 per ten thousand. The influence of 
race upon infant mortality may therefore be summed up as follows: 

The highest death-rate from congenital causes is among children of 
native parents, the highest death-rate from infectious diseases is among 
children of Italian mothers, the highest death-rate from acute respira- 
tory diseases is among children of Italian mothers, while the highest 
death-rate from diarrheal diseases is among children of English and 
native parents. It is impossible to quote figures taken ten or twenty 
years ago in regard to this matter but experience of health workers in 
large cities would seem to point to a marked change from the conditions 
enumerated. 

In the early years of child welfare work it was apparent that the 
highest infant mortality occurred in practically all classes of disease 
among children of foreign parentage. That in at least two instances — 
congenital diseases and diarrheal diseases — the highest mortality-rate 
is in children of native parentage offers a subject for consideration in 
planning programs for child welfare at the present time. 

Economic. — Poverty, and therefore wages, in relation to infant 
mortality, is fundamental. If a living wage and universal education 
in health matters prevailed it is possible that the infant mortality-rate 
could be reduced to an, at present, inconceivable minimum. Students 
of sociology have a well-grounded basis for their belief that poverty is 
the basis of practically all morbidity occurring in that group of people 
whose wages are below the limit which provides decent living condi- 
tions. The Johnstown report gives definite relation between the 
wages of the father and the infant mortality. It was shown in that 
investitation that where the father earned less than $521 per year the 
infant death-rate was 255.7 and where the father earned more than 
% 1200 per year the infant death-rate was 84. The rate of wages, how- 



INFANT MORTALITY 677 

ever, must be considered in relation to other related circumstances. 
For example a low rate of wages for the man of the family results 
almost invariably in forcing the mother into industry. The question 
of the effect of industry upon the health of potential or expect 
mothers is one that has not yet been sufficiently studied. It has been 
found, however, that in the industrial sections of England where 
41 per cent, of the mothers are employed, the infant mortality-rate is 
150 and in those industrial cities and towns where 88 per cent, of the 
mothers are employed, the infant mortality-rate is 182. The result 
of industry upon the health of the expectant mother or the potential 
mother has not been reduced to statistical form. Much depends upon 
the character of the occupation, including the amount of fatigue, 
physical strain, insanitary environment, length of hours of work, 
hazards which may result in accidents, the presence of poisonous fumes 
or irritating dust. By-products of women in industry which are 
sometimes shown in either ignorance of child care or neglect of the 
child while the mother is working, all have a direct bearing upon the 
infant mortality-rate. 

This early neglect of children is reflected in the figures quoted in 
England by Newman which show that when a mother returns to work 
in less than a month after confinement, the infant death-rate was 
136.7, and that when the mother returned to work one month or more 
after confinement, the infant death-rate was 112.5. Attention has been 
called to the effects of subnormal living conditions upon the pregnant 
women by a realization of the large proportion of deaths under one year 
of age which occur in the first month of life, amounting to 38 per cent, 
of the total. As practically all these deaths are due to so-called 
"congenital diseases" and are the result of the physical condition of 
the mother before the baby is born, it may readily be seen that all 
social, economic and environmental factors which tend toward lowered 
hygienic conditions during the period of pregnancy have a marked 
effect upon the infant mortality-rate in the early months of life. The 
soundness of this reasoning has been proved by the results which have 
been achieved as a result of so-called "prenatal work" where the 
infant mortality in the first month of life has been reduced one-half 
as a result of proper supervision of the expectant mothers. This 
matter will be considered later under "measures for reducing infant 
mortality." 

Illegitimacy. — The death-rate among illegitimate children is abnor- 
mally high. Generally, in the United States, the fact of illegitimacy is 
not recorded. It is therefore difficult to obtain exact statistics except 
from European countries. In England, however, it has been found 
that deaths among children born out of wedlock are from two to two 
and a half times as great as the number among children born of wedded 
parents. The cause of this excessive death-rate is found in the natural 
weakness of the children as a result of the great mental strain on the 
part of the mother, with resultant physical weakness and lack of 
vitality, and also the neglect of the child during the early period of 
infancy which is so common under such circumstances. 



678 CHILD HYGIENE 

TABLE IV. — DISTRIBUTION OF INFANT MORTALITY IN THE UNITED STATES 
(CENSUS OF 1910) BY CAUSES. 

No. Per cent. 

Congenital diseases 46,852 0.30 

Diarrheal diseases 45,440 0.29 

Respiratory diseases 23,187 0.14 

Contagious diseases 6,092 0.04 

Other causes 32,792 0.21 

Congenital Diseases. — The causes of this — the highest group of deaths 
under one year of age — have been partially discussed before. In 
detail, however, we must consider: 

1. Prematurity. — This is due usually to syphilis or to social or 
economic factors which are affecting the health of the expectant mother. 
As a cause of infant deaths, syphilis does not rank high, giving from 
1.2 to 2 deaths per thousand births. The reason for this is that prac- 
tically all syphilitic conceptions result in stillbirths. If the syphilis 
has occurred in the mother, the stillbirths may range from 60 per cent, 
to 100 per cent, of all conceptions; if the infection is directly from the 
father, the mortality is much lower — from 28 per cent, to 35 per cent. 
The other causes of prematurity are those of extremely lowered vitality 
of the mother due to underfeeding or overwork or to actual undue 
physical strain or accident. 

2. Feeble Vitality. — Feeble vitality furnishes by far the greatest 
number of deaths from congenital diseases. The causative factors in 
the mother are all that relate to poor social and economic conditions, 
including overwork and strain, industrial diseases, lack of food, or of 
fresh air and general unhygienic living conditions. Feeble vitality as 
a cause of death in the infant is simply an expression of the lack of 
physical power to live, dependent upon the lowered physical vitality 
of the mother. 

3. Accidents of Labor. — This group is so small that it cannot be 
considered as a public health problem. 

4. Alcoholism. — Alcoholism as a cause of deaths from congenital 
diseases does not rank high. There can be no question that if alcohol 
circulates in the blood of the pregnant woman it will reach the fetus 
and injure the tissue for the proper development of the cells. Such 
cases, however, are difficult of actual tabulation. The main result of 
the effect of alcoholic parents upon the deaths of children is found 
under the age of two years, where we may consider the results due to 
environment and resultant neglect rather than to heredity. Studies 
of groups of such children under two years of age have shown that the 
death-rate of children of drunken mothers was 55.2 as compared with 
a death-rate of 23.9 among children of sober mothers in similar environ- 
ment. 

Diarrheal Diseases. — From a public health point of view, the cause 
of diarrheal deaths must be considered as dietetic. The specific 
bacteriological cause of such diseases is of marked interest and should 
be considered, but from the point of view of handling the problem the 



Infant mortality 



679 



question of feeding assumes paramount importance. Heat in its 
relation to the reduction of infant mortality has been considered an 
important factor. Results shown, however, in cities where adequate 
infant welfare work has been carried on, have demonstrated without 
question that the infant mortality-rate may be kept as low in summer 
as it is in winter. The effect of heat upon infant mortality is shown 
mainly in two directions: (1) In lowering the general vitality of the 
infant. The heat centers of the young child are much more unstable 



DEATH BA7ET COM ALL CAU5E5 IN CHILDREN UNDER ONE YEAR OF AGE PER 1000 BIRTH5 
NEW YOPK CITY COMPARISON OF YEARS 1907 AND 1913 


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Fig. 105 

than are those of the adult. The infant, therefore, is apt to feel the 
effects of severe heat much more than the adult. (2) The effect of heat 
upon milk is a matter which need not be discussed here. Undoubtedly, 
the vast epidemics of diarrhea in the past have been due largely to this 
factor. With the improvement in the condition of the milk supply, 
the almost universal pasteurization of milk and the extended public 
health education of mothers in the care of milk in the homes, this 
problem has been practically solved. 



6S0 CHILD HYGIENE 

A chart showing the status of the infant death-rate in New York 
City in 1907 and 1913 is shown herewith. 1907 is taken as represent- 
ing the increased baby death-rate during the months of July and 
August which obtained up to that year and for two or three years 
afterward. About 19 10 this summer rise began to decrease in a marked 
manner and the line for 1913 shows about the average status of the 
summer increase since that time. For the past five years the general 
infant mortality curve has been little, if any, higher during these two 
summer months than during the spring months. The actual heat, 
therefore, would seem to bear a less distinct relation to the production 
of diarrheal diseases than has been thought to be the case and it may 
be stated that its effects may be completely nullified by proper super- 
vision of mothers and babies. 

Respiratory Diseases. — Little is known of the causative factors 
of the death-rate from respiratory diseases except when they occur 
as terminal conditions of one of the infectious diseases, particularly 
measles or whooping-cough. In such instances the causative factor 
relates to the original disease, and methods for dealing with these cases 
must be considered from that point of view. In common with the 
occurrence of respiratory diseases among adults, we find striking con- 
firmation of the belief that they are closely allied to lack of ventilation 
and bad air. 

Contagious Diseases. — These furnish only 4 per cent, of the total 
deaths under one year of age and are of interest more because of their 
sequela? or complications than because of their place as a cause of 
deaths in infants. Two diseases that are of particular importance at 
this time are measles and whooping-cough, both of which are diseases 
of severity when occurring in children under one year of age. 

REDUCTION OF INFANT MORTALITY. 

Complete and adequate birth registration is the foundation of all 
effective programs for baby saving. For methods of obtaining such 
registration, reference should be made to standard text-books on 
vital statistics. Programs for the reduction of infant mortality 
must have as their first point of attack the reduction of infant mor- 
bidity. It may be stated that any efforts which result merely in 
reducing the number of deaths under one year of age cannot be 
considered as satisfactory. The problem of child welfare is not one 
of an individual age group. The true test of the efficacy of public 
health work for the reduction of the infant death-rate must be found 
not in the infant death-rate itself but rather in the death-rate of the 
succeeding years of child life. The reduction of the morbidity and 
mortality-rates under five years of age, therefore, are the final measures 
of the efficiency of the work directed at the reduction of the death-rate 
under one year. 

Community Program. — The early steps to combat the excessive infant 
morbidity- and mortality-rates must be those pertaining to community 



REDUCTION OF INFANT MORTALITY 681 

sanitation, general hygiene, improved housing, prevention of over- 
crowding, provision of a pure water and pure milk supply and proper 
facilities for recreation and fresh air and the control of infection. 

Unless a community is particularly progressive, it is probable that 
a large amount of public education will have to be carried on before 
even a modest program can be put into effect. The first step, there- 
fore, should be to arouse community interest. This is often best done 
at first through the medium of local clubs, churches or welfare organiza- 
tions. The ultimate responsibility, however, should rest upon the 
health department and as soon as possible the work should be placed 
under their direct control. In order to determine the extent of infant 
mortality in a community, it is necessary to have accurate vital 
statistics. If these are not available, a survey of the community 
should be made, including a study of the births and deaths. These 
should be graphically portrayed by means of pin maps so that the 
number and places of the births and the number, places and causes 
of the infant deaths may be readily apparent. A public exhibition 
should be made of such map, at local meetings, where doctors and 
nurses may call attention to the infant death-rate of the community 
and the reasons why such work is essential. As publicity is such an 
important factor in a campaign of this type, the close cooperation of 
the public press is essential. 

Local boards of health must be held responsible for the general 
sanitation of the community and the laws relating to proper housing 
facilities, and these should be rigidly enforced. The provision of a proper 
milk supply is of the utmost importance and unless it can be determined 
beyond the question of a doubt that the milk supply of a community 
is perfectly safe, laws requiring pasteurization should be passed and 
enforced. While the instruction of the mother in the care of the child 
should rest entirely upon methods concerned with public health educa- 
tion, it may be necessary to have certain legislation affecting the 
community as a whole. Such legislation should include (a) provision 
for maternal insurance or payment of a subsidy to pregnant women at 
the time of and for at least four weeks after confinement, (b) laws 
preventing women working for at least one month before and one 
month after confinement, and (c) laws regulating hours and conditions 
of women working outside the home. 

Individual Program. — Public health work in baby care should consist 
of one or more of the following factors : 

(a) Prenatal work. 

(b) Baby health centers or infants' milk stations. 

(c) Home visiting by nurses. 

(d) Mothers' conferences. 

(e) Little Mothers' Leagues. 

(/) Public health education, including lectures, educational litera- 
ture, pamphlets and newspaper articles. 

(g) Auxiliary aids and cooperation of all infant welfare organizations. 



682 CHILD HYGIENE 

Prenatal Work. In the registration area of the United States in 1910, 
30 per cent, of all deaths under one year of age occurred from congenital 
diseases, thus being the cause of the greatest proportion of infant 
deaths. Efforts to reduce this death-rate, which occurs almost entirely 
during the first month of life, are based upon proper supervision of the 
health of the mother before the child is born. In order that this super- 
vision may be effective, the mother should be reached as early in 
pregnancy as possible. While a great deal of proper preventive work 
may be done after the third month of pregnancy, it becomes increas- 
ingly difficult from that time on and after the sixth month it is prob- 
ably little more than supervisory. 

Knowledge of these expectant mothers may be obtained through 
information furnished by social workers, welfare centers, visiting 
nurses or by the voluntary registration of the women themselves at 
some local center. Prenatal nurses, on their first interview with the 
expectant mother, should determine whether or not a physician or 
midwife has been engaged for the confinement. If not, the nurse 
should get into immediate communication with a hospital or physician 
and see that the expectant mother is at once examined. Throughout 
the period of supervision the nurse should remain in touch with the 
doctor in charge of the case and should report to him at once any 
evidence of abnormal symptoms occurring in the expectant mother. 
Visits should be made by the nurse every three weeks up to the fifth 
month of pregnancy and then every ten days until delivery. In 
abnormal cases visits should be made as often as indicated. After 
birth of the child the case should be visited every day for a week and 
then every five days until the end of a month. At the end of that 
time the baby should be referred to a baby health station for continued 
supervision. 

The type of instruction to be given by the nurse to the expectant 
mother should include full directions regarding sanitation of the home 
including its cleanliness and proper ventilation. The patient must 
be carefully instructed regarding proper diet, clothing, exercise, rest, 
bathing, care of the teeth and of the breasts and whatever instructions 
may be necessary in individual cases. The urine should be examined 
at least once a month and if any abnormality is discovered, such fact 
should be reported to the physician at once. The patient should be 
instructed that if any of the following symptoms occur a physician 
should be sent for at once and the nurse notified : Severe and persistent 
vomiting, constant headache, swelling of the legs or ankles, scanty 
urine, muscular twitching, convulsions or bleeding. Any symptom 
which would seem to be suggestive of tuberculosis or syphilis should 
lead to immediate medical care and in each case of suspected syphilis 
a Wassermann test should be made. 

Maternity Centers. — In order to make prenatal care more universal 
and to educate the public as to its necessity as well as to provide 
proper supervision of the expectant mothers, maternity centers may be 
organized. These centers should be in the nature of educational 



REDUCTION OF INFANT MORTALITY 683 

centers. At certain hours of the week a doctor should be present to 
examine the expectant mothers and make a complete clinical record of 
their condition. A registrar should be provided also, to be in charge 
of the clinic and of the records. All child welfare agencies in the 
vicinity should cooperate with the maternity center by referring thereto 
all expectant mothers who apply to them for care, and such others as 
they may be able to enroll. Such maternity centers do not supplement 
the work of other organizations nor should they necessarily be entities. 
They serve rather as clearing houses in order to prevent duplication of 
effort and all prospective mothers enrolled and examined at these 
centers are thereafter cared for by the agency who is working in the 
district in which the prospective mother lives. While it is not advised 
that the public health nurse should care for the mother during her 
confinement, it is desirable that some nursing care should be arranged 
for. Probably the best arrangement would be adequate facilities in 
lying-in hospitals, with competent medical and nursing care. When 
this cannot be obtained, however, it may be seen that the careful 
supervision of the midwife, who carries on both medical and nursing 
functions, is of the utmost importance. As the greater part of the 
reduction of infant mortality in this country has taken place in the 
class of cases known as diarrheal diseases, with a lesser reduction in the 
respiratory disease and contagious disease groups, it is evident that in 
the future more strenuous efforts must be put forth in the line of reduc- 
tion of the infant death-rate from congenital causes. 

The methods outlined have been shown to be effective. In prac- 
tically every town where they have been tried, including Boston and 
New York, the infant death-rate of the babies of mothers who have 
been under supervision during their term of pregnancy has amounted 
to a little more than half that of the general city rate for the same 
period. Not only has the infant death-rate been thus decreased 50 
per cent, during the first month of life, but the effects are equally good 
in the opportunity which is given of reaching the baby at the beginning 
of its life, when education of the mother as to the necessity of breast 
feeding can be carried on with the least amount of resistance, and in 
the cases under supervision in New York City it was shown that 94 
per cent, of the children were entirely breast fed at the end of one 
month. The educational possibilities of this line of work, therefore, 
are of the highest importance. Moreover, by keeping the child under 
continuous supervision from birth throughout the first and second 
years, almost perfect health control is assured. Such work meets the 
test already outlined of effective public health work for infants by not 
only saving life but assuring the almost total absence of morbidity 
during the first and succeeding years. 

Baby Health Stations. — The term "baby health stations" is used to 
designate the various infants' milk stations, infant welfare centers and 
other organizations of similar type. In the past their function was. 
largely concerned with the provision of a proper type of milk for infant 



684 CHILD HYGIENE 

feeding and the necessary instruction to see that such milk was properly 
prepared. In later years their educational functions have been much 
extended until now their main object is the extension of breast feeding 
to all infants and the necessary instruction of the mothers by trained 
nurses in all methods of proper baby care. The infants' milk stations 
or baby health stations are a direct outgrowth of the "consultations 
de nourissons" which were established in 1890 by Professor Budin at 
the Charite Hospital in Paris and the "goutte de lait" which was 
established in Paris in 1892 at the Belleville by Professor Leon du Four. 
The consultation de nourisson was associated with the lying-in hospital 
and was simply an attempt to continue supervision of the babies born 
there. They were required to be brought back once a week for weigh- 
ing. Breast feeding was encouraged but if this was impossible, steril- 
ized milk was given out by the clinic. Our present milk stations are 
more in the nature of the goutte de lait. Here milk was distributed 
for infant feeding and a beginning was made in pasteurizing and modify- 
ing the milk for that purpose. 

The first infants' milk station in the United States was started by 
Nathan Straus in New York City in 1898. This followed closely the 
type of the goutte de lait. Milk already modified according to certain 
prescribed formulae for different ages was placed in individual feeding 
bottles and when a baby was registered at the station the mother could 
procure each day the proper amount of food for her child on payment 
of the cost price. No physicians or nurses were in attendance. The 
value of these stations was very great at the time they were started 
because the community milk supply at that time was not carefully 
supervised and the milk sold at the Straus stations, which was all 
pasteurized, was the best milk which could then be obtained. Since 
then pasteurization has become general and the tendency in baby health 
stations has been away from accentuation of them as places for the dis- 
tribution of milk toward what should be their real function — that 
of educational propaganda in the care and feeding of young children. 

Modern baby health stations, or milk stations, therefore, are gener- 
ally of two types: (1) Where the milk is modified according to certain 
prescribed formulas for certain ages, either in a central laboratory or at 
each station, and distributed only after the baby has been examined 
by the physician in attendance at the baby health station, who pre- 
scribes a certain standard formula of milk for the child. In addition, 
individual formula? may be made, if so prescribed. In these stations 
doctors and nurses are assigned to examine the babies and also to see 
that the mothers are instructed in all methods of baby care. (2) The 
second type of station is that in which whole milk is distributed in 
quart bottles. Each baby is examined by the doctor and an individual 
formula prescribed in each case. One copy of this formula is given to 
the mother and the other to the nurse. The nurse instructs the mother 
at the station how the formula should be prepared and in addition 
visits the home to reinstruct her until it is evident that the mother is 



REDUCTION OF IXFAXT MORTALITY 685 

entirely competent to prepare the milk. The value of this method lies 
in (a) the lessened cost of the day's feeding, (b) the educational value to 
the mother in the opportunity afforded to visit her in her home and offer 
public health education and (c) the flexibility of the feeding system 
which insures definite attention to each child's needs. 

Organization of Baby Stations. — The stations should be open from 
S a.m. to 1 p.m. daily and from 8 a.m. to noon on Saturdays for instruc- 
tion and advice and from 8 a.m. to 10 a.m. on Sundays and legal holidays 
for the distribution of milk only. 

Before establishing a station, a study should be made of those 
sections of the city where it is felt that the need for such organization 
is greatest and the following factors taken into consideration : Infant 
mortality-rate, birth-rate, child population, congestion of district, 
housing, general intelligence of parents, and economic status of popula- 
tion, etc. If other agencies performing similar work exist in any given 
district, the baby health station should be established in some other 
section in order to avoid duplication of effort. 

The education of the laity to the importance and advisability of 
breast feeding should be kept foremost in the educational propaganda. 
Only when absolutely necessary should artificial feeding of babies be 
allowed or countenanced. In order to meet the situation of babies 
who must be artificially fed, a high grade of safe, clean milk, known in 
Xew York City as "Grade A pasteurized'' should be sold in bottles, at 
a price usually from three to three and a half cents below the prevailing 
market price. In selected cases of want, milk may be provided free 
of cost, through the organized charities and other agencies. 

The temperature of the milk should be tested daily at each station 
and bacteriological and chemical analyses should be made regularly 
in the laboratory of the board of health in order to ascertain the 
bacterial content and quality of the milk. 

Each station should have a nurse and a nurse's assistant in attend- 
ance daily. One doctor may be provided for three stations, attending 
each twice a week. During the summer months the regular baby 
health station service should be augmented by the employment of 
additional nurses and doctors. 

The sites selected for baby health stations should preferably be 
stores consisting of four rooms each : the first for a dispensing room for 
the distribution of milk, the second a waiting room for dressing and 
undressing the babies and weighing the children, the third a demon- 
stration room for preparing milk formula? and holding mothers' classes 
and the fourth a consultation room where the doctor examines the 
babies and instructs the mothers. 

Full equipment at the stations varies somewhat with the premises 
available. The following list of equipment for use at the baby health 
stations is inclusive of all articles in the best equipped stations but 
a much less elaborate equipment will provide everything actually 
essential: 



686 CHILD HYGIENE 

Equipment for Baby Health Station. — 

1 zinc top dispensing table 
1 large steel enameled table 24 x 60 
1 small steel enameled table 20 x 48 
1 desk, white enameled steel 
1 supply closet, white enameled 
1 wardrobe, white enamel 
18 wooden folding chairs at $20 per dozen 

3 steel white enameled chairs at $2.89 each 

1 box for record cards 

2 laundry bags 

1 wire scrap basket 
1 clock 

1 scale and scoop 
1 infant's bath tub 
1 three-burner hot plate 
1 double boiler, two quarts 
1 saucepan, two quarts 
1 tea kettle, three quarts 
1 dishpan, fifteen quarts 
1 tray, white enamel 
1 strainer with hook 
1 bowl, two quarts 
1 funnel, half pint 
1 pitcher, one quart 
1 basin, white enamel 
1 cup, eight ounces, with handle 
1 glas? jar, one quart, with cover 
1 glass graduate, eight ounces 
6 glass tumblers, eight ounces 
1 soap dish, white eramel 

Thermometers, one each, dairy, room, clinical, bath 
1 can opener 
6 bottle washers 
6 teaspoons 
6 tablespoons 
6 knives 
40 yards linoleum at $1 . 00 per yard 
1 refrigerator 
1 hospital screen, white enameled where necessary 

4 window screens at $1.00 
1 door screen 

1 towel rack, wood, three-prong 

1 rubber door mat 

2 asbestos mats 

1 ash can, No. 9 (where necessary) 

Brushes: nail, .10; scrub, .15; window, .50; sink, .10; stove, .25 

1 broom 

1 dustpan 

1 mop, cotton twine, with handle 

1 mop wringer 

1 metal pail 

1 coal hod (where necessary) 

1 large shovel (where necessary) 

1 small shovel (where necessary) 

1 rubber squeegee and handle 

1 stepladder 

1 tool combination plier 

1 fountain syringe, two quarts 

1 catheter, 17-French 

Shades, 4 window and 1 door at $1 . 50 each (where necessary) 

Gas radiator (where necessary) 

Stove (where necessary) 



REDUCTION OF INFANT MORTALITY 687 

The service at the stations should be supplemented by home visits 
by the nurse, usually in the afternoon, when full instruction in diet, 
hygiene and sanitation should be given to the mother. Supplemental 
literature regarding baby care should be distributed as indicated. 
Mothers should be instructed to bring their babies to the station once 
a week on a given day for weighing purposes, and more frequently if 
the baby is ill or delicate. 

If the mother fails to bring her baby on the regular weighing day, 
a visit to the home should be made to ascertain the cause for non- 
attendance and if, after reasonable warning, the mother does not bring 
the child to the baby health station within a period of three weeks, the 
case may be terminated unless the reasons are such as to satisfy the 
nurse in charge that the mother is unable to attend. The enrolment 
at the baby health station should be maintained throughout the year 
by house-to-house canvass of the neighborhood by the nurses and 
nurses' assistants. 

The physicians in attendance at the baby health stations should 
not treat any cases of illness if the parents are able to afford the services 
of a private physician. Occasionally, cases of acute illness may be 
given emergency or first-aid treatment and then subsequently referred 
to the private physician, if the family is able to pay. General diseases, 
such as bronchitis, pneumonia, contagious diseases, etc., should not be 
treated under any circumstances, except as aforenoted. Cases of 
gastro-enteritis and of malnutrition, if unable to pay for the services of 
a private physician and unwilling to visit the dispensary, may be taken 
care of by the baby health station service. 

Instruction should be given at the station in all matters of child 
diet and child care and each case should be treated individually by the 
inspector as regards milk modification. The formula prescribed by the 
physician in attendance should be demonstrated to the mother, both 
at the station and in the home, until the nurse is satisfied that the 
mother understands. 

Aims and Objects of the Baby Health Stations. — The aims and. objects 
of the baby health stations are : 

1. To supervise expectant mothers during pregnancy, the lying-in 
period and for at least one month after the birth of the child, through 
the prenatal service of the station. The baby is then transferred to the 
regular baby health station service. 

2. To advise mothers with regard to the care and feeding of babies 
under two years of age. 

3. To encourage, secure and maintain, entirely or in part, breast 
feeding. 

4. To supply, when artificial feeding is necessary, a good grade of 
clean, safe milk at lower than the market price, for those who are 
unable to pay the latter. 

5. To prevent, by educational and prophylactic measures of child 
hygiene, the diseases of infancy and childhood caused by errors in diet 
and unhealthful living and, by such teaching, to minimize the possi- 
bility of illness. 



088 CHILD HYGIENE 

6. To serve as bureaus of information or community centers to which 
the inhabitants of the neighborhood may come for advice and assistance 
regarding the health and physical welfare of the entire family. 

7. To effect not only a reduction of infant morbidity and mortality 
but, indirectly, to promote the general good health and well-being of the 
entire family by bringing into the home rules for healthful living. 

The main effects of the baby health stations have been the reduction 
of the infant death-rate from diarrheal diseases and the improvement 
in the general health of the infants so that the death-rates from res- 
piratory and contagious diseases have also been materially reduced. 
In the registration area of the United States for 1910, diarrheal diseases 
furnished 29 per cent, of the deaths under one year of age, respiratory 
diseases 14 per cent., contagious diseases 4 per cent, and the other 
miscellaneous causes 21 per cent. 

As the prevalence of diarrheal diseases may be considered to depend 
upon the extent of dietetic errors in infancy, it is evident that efforts 
directed toward providing a clean, natural feeding for the child are the 
best to use in reducing the death-rate from these causes. Whenever 
it is possible, without serious detriment to the mother, breast feeding 
should be insisted upon. It will be found that among babies of mothers 
of foreign parentage, breast feeding is almost universal during the first 
three months of the baby's life. It is stopped later, usually, because 
of the mother's desire to go to work or to her belief that substitute 
feeding is just as good for the baby. Probably 95 per cent, of the 
mothers are physically able to nurse their infants during the first six 
months. In a study made to determine the importance of breast 
feeding in the prevention of infant mortality conducted by the Bureau 
of Child Hygiene of the Department of Health of New York City some 
years ago, embracing about four thousand children between three and 
twelve months of age, it was found that 79 per cent, of these babies 
were breast fed exclusively, 13 per cent, were fed on bottled milk 
exclusively, and 8 per cent, on bottled milk and breast milk combined. 
It is safe to say that about 80 per cent, of the tenement population 
nurse their babies exclusively. 

The infant death-rate, in general terms, is directly the opposite of 
the manner in which the babies are fed. It has been estimated that 
from 75 per cent, to 85 per cent, of all infant deaths occur among those 
artificially fed. Holt has stated that '''The difference in the mortality 
of these two classes (breast fed and bottle fed) is most striking. The 
Health Department estimates that 85 per cent, of all infantile deaths 
are in those artificially fed. This statement is borne out by figures 
drawn from other sources. Tyson states that of 150,000 infantile 
deaths in Great Britain, 75 per cent, were in those who were artificially 
fed. Kober states that of 54,047 infantile deaths investigated at 
home and abroad, with reference to feeding, 86.6 per cent, were arti- 
ficially fed. In Munich, the mortality in breast-fed babies is stated to 
be 15 per cent, while in bottle-fed infants it is 85 per cent." 

vSeveral investigations have been made by the Bureau of Child 



REDUCTION OF INFANT MORTALITY G89 

Hygiene of New York City as to the character of feeding in infant 
deaths from diarrheal diseases. Almost invariably, it was found that 
of 1000 deaths from this condition, approximately 90 per cent, were 
babies artificially fed and 10 per cent, infants fed on the breast. 

As late as last year a study was conducted by the Bureau of Child 
Hygiene of Xew York in connection with the Mayor's Milk Investiga- 
tion Committee, with a view to determining the relation of the char- 
acter of feeding to deaths from diarrheal diseases in infancy, and 
accurate information was obtained in 1065 cases, with the following 
results : 

Character of feeding. No. of cases. Percentage of cases. 

Breast feeding only 178 16.7 

Breast and bottle ■ ... 154 14.4 

Breast and other 67 6.3 

Breast and loose 11 1.0 

Bottle only 286 26.9 

Bottle and other 221 20.7 

Bottle and loose 10 1.0 

Loose 22 2.1 

Loose and other 25 2.4 

Other 91 8.5 

These figures, showing 17 per cent, of the babies who died were 
exclusively breast fed and 83 per cent, artificially fed, offer a convincing 
argument for maternal nursing as a preventive, at any rate, against 
gastro-enteric diseases. These figures are, furthermore, corroborated 
in the article by Holt, who states: "Hope of Liverpool has shown 
that in 1000 breast-fed infants under three months of age, there were 
only 20 deaths from diarrheal diseases, while of 1000 bottle-fed infants 
there were 300 deaths. Of 1000 fatal cases of diarrheal diseases 
investigated by the Xew York Department of Health in 1908, only 
90 had previously been entirely breast fed. Xewsholme gives almost 
the identical figures for England, namely, 10 per cent, of infant deaths 
from diarrheal diseases in breast-fed infants and 90 percent, in bottle- 
fed infants." 

If artificial feeding must be resorted to, cows' milk of the highest 
grade, certified if raw or pasteurized if any doubt exists as to the condi- 
tions under which it was produced, should be used as the basis for feed- 
ing, and should be modified to suit the needs of each individual child. 
Methods and types of modification may be left to the discretion of the 
individual physician. In Xew York City dilution of whole milk, with 
the addition of the required amount of milk sugar and lime water, has 
proved peculiarly efficacious. 

Methods of computing mortality in the baby health stations have 
been open to question. The usual method is to consider the station 
as responsible for the death of a baby when it occurs at any time from 
illness contracted while on register at the station. The variability of 
standards in this direction, however, has given rise to a great deal of 
misconception in this regard. It is probable that percentage statistics 
of this type are no more than an indication of the effect of the station 
44 



690 CHILD HYGIENE 

upon the reduction of infant mortality. Other methods have been 
advised and suggested from time to time, notably that of computing 
the total number of days' attendance at the baby health station, divid- 
ing this by 365, the number of days in a year, and then computing the 
death-rate for the year on the so-called "infant days" or the number of 
days the infants were in attendance. This method has its disadvan- 
tages in that it does not take cognizance of the educational value of the 
stations and the fact that their effects may be expected to be more 
potent when the babies have been in attendance for some time, also 
that the baby health station is in no sense a clinic, so that children in 
attendance for a short time who die of acute disease do not truly 
represent the value of the station's methods. However, this method 
may be accepted at the present time as only one of the standard means 
of determining the death-rate at such stations. 

While the death-rate based upon the actual deaths of infants com- 
puted on the total attendance may range from 10 to 25 per thousand, 
the death-rates based upon the infant year plan have shown a death- 
rate of 42 per thousand in the Baby Health Stations of New York City, 
whereas the total infant death-rate for the city for the same year 
was 93. Even this severe test shows that the baby health station, 
as a measure in reducing the infant mortality-rate, has justified itself. 
Where they have been used in large numbers the effect upon the infant 
mortality-rate has been immediate and progressive. The baby health 
station of the future, should be planned so that its functions may 
include supervision of the health of the child from birth to school age. 
It should be a community health center for young children. The 
prominence of milk as a factor in the reduction of infant mortality from 
the baby health station point of view should be continually minimized. 
The provision of a safe milk supply in the city must be accentuated. 
As soon as it is obtainable the baby health stations should be educa- 
tional centers only, and milk should be bought at other available 
places. This work can be carried on at an average cost varying from 
sixty cents to a dollar and a half per month per baby 

Home Visiting by Nurses. — One of the defects of the baby health 
stations is the fact that the ages of their clientele average between 
four and six months of age at the time of admission. For the purpose 
of furnishing more adequate health education of the mothers, there- 
fore, the visiting nurse may be used. While it is true that a nurse in a 
baby health station may see more mothers in a day than she could visit 
in the same space of time, it is also true that unless the community 
consists of widely-scattered dwelling places the nurse doing home 
visiting may care for at least one hundred and fifty babies, each to be 
visited once in ten days. The proper method is to have the nurse 
receive a copy of all birth certificates filed the previous day and relating 
to babies in her district. These children should be visited at once. 
Depending upon the length of time allowed by law for reporting births, 
it may be seen that such children would be visited from three to ten 
days after birth, at a time when breast feeding is practically universal 



REDUCTION OF INFANT MORTALITY 691 

and when there is every opportunity to give the mother the proper type 
of instruction in caring for her baby. A visit once in ten days is ade- 
quate for the normal child. Sick or delicate babies should be visited 
more often. At each visit the mother should be instructed as to the 
value of breast feeding and should be given definite and detailed instruc- 
tion and demonstration as to the hygiene of infancy, including clothing, 
bathing and the value of fresh air, as well as instruction pertaining to 
the hygiene and sanitation of the home. This plan of work has certain 
distinct advantages: (1) It enables the nurse to reach the parents 
almost as soon as the baby is born and (2) it is distinctly less costly 
than the establishment of baby health stations. It has been found 
possible to carry on this work at a total cost of from fifty to sixty cents 
per month for each baby cared for. It has the disadvantage, however, 
of not providing any place where mothers may bring their children at 
any time with the surety of finding some person to advise them and it 
lacks the educational advantages which result from the publicity 
given. a local baby health station or baby welfare center. For small 
towns, however, it offers an opportunity for effective work if funds 
cannot be raised at once to establish a baby health station. 

Conferences of Mothers. — As part of a well defined program for the 
reduction of infant mortality, arrangements should be made whereby 
conferences can be held with groups of mothers at stated intervals. 
These conferences should be presided over by a physician or nurse and 
the mothers should be given direct, practical talks, with actual demon- 
stration of different methods of child care. While this holding of 
conferences has a distinct value, they should not be conducted at the 
cost of more effective baby welfare work in other directions. They 
must be considered as an auxiliary only. 

Little Mothers' Leagues. — Little Mothers' Leagues originated in the 
Bureau of Child Hygiene of New York City in 1910 as a result of the 
realization that a large number of the babies of the city are cared 
for by little girls of from ten to thirteen years of age. As the social 
and economic conditions hi the city seemed to make this inevitable, 
it was felt that these children should be taught how to care for babies, 
not only to provide the proper care for the children under their control 
at that time but also that they might in turn carry these instructions 
to their mothers and, most important of all, that they might receive 
instruction which would enable them to care for their own children 
later. 

The organization of these leagues can be accomplished as follows : 

First, the public should be informed regarding the proposed leagues 
by (a) a general public lecture or (b) separate lectures in each public 
school of the city. It is recommended that girls from ten to fourteen 
years of age be considered eligible. If such instruction in personal 
hygiene and care of the baby can be made part of the regular school 
curriculum, such a course should be taken. Only in the event of the 
refusal or inability of the school authorities to provide this teaching 
should the work be assumed by the health authorities. In such case, 



692 CHILD HYGIENE 

the leagues may well be held only from the closing of school in the late 
spring to their reopening in the fall. If possible, however, they should 
be conducted throughout the year. 

At the preliminary meeting, the children should be asked to become 
voluntary aids of the board of health in saving the lives of babies and 
should be required to sign pledge cards signifying their intention to 
attend the meetings. At the first meeting of the children the organiza- 
tion may be effected, with the nurse as honorary president and two 
of the children elected president and secretary. An outline of the 
business meetings may be evolved to suit local needs. In general, 
however, at each meeting there should be a short talk by the nurse on 
some one method of baby care, to be followed by actual demonstration. 
Each child should be required to perform the actual work of milk 
modification, dressing or bathing the baby, until it is evident that it 
is well done. Several lessons may be spent on one topic. The lessons 
that are suggested herewith are merely advisory for a short course. 
They may be extended to include various other subjects, including 
personal hygiene of the girls themselves. 



SUGGESTED LESSONS FOR LITTLE MOTHERS LEAGUES. 

1. Growth and development; special senses. 

2. Teeth. 

3. Water — internally and externally; special baths. 

4. Fresh air. 

5. Sleep and quiet. 

6. Clothing and cleanliness. 

7. First care of sick baby. 

8. Difference between mothers' milk and cows' milk. 

9. Amount and intervals of feeding. 

10. Care of milk; bottles; nipples. Articles needed for home 
modification of milk. 

11. Directions for home modification of milk. 

12. Instructions for making albumen water; whey. 

13. Quiz on previous lessons. 

The children should be encouraged to write essays about the lesson 
topics and also to write descriptive plays, illustrating the various points 
they have learned. These plays should be acted by the members of the 
leagues. This method furnishes a graphic form of teaching, which 
has been found to be unusually successful. Many ways of developing 
the Little Mothers' League will present themselves to any interested 
person. The work should be made as joyous as possible and the 
children encouraged to have picnics, outings or other forms of enter- 
tainments which will take away from the leagues the idea of an auxil- 
iary school. Simple equipment is necessary and may be modified to 
suit the needs of the various localities. The following is suggested: 



REDUCTION OF INFANT MORTALITY 693 



EQUIPMENT FOR LITTLE MOTHERS' LEAGUES. 

Gas stove and tubing. 

Bathtub. 

Double boiler. 

Dish pan, two quarts. 

Bowl, two quarts. 

Tea kettle, two quarts. 

Pitcher, one quart. 

Tumbler. 

Glass graduate, eight ounces. 

Funnel. 

Scale. 

Basket. 

Strainer. 

Bath thermometer. 

Clinical thermometer. 

Baby bottles, four 8-ounce. 

Nipples, four. 

Knife. 

Tablespoon. 

Toothbrush. 

Safety pins. 

Piece of castile soap. 

Piece of rubber sheeting or pad. 

Bath towels, two. 

Face towels, two. 

One pound package absorbent cotton. 

Five yard package gauze. 

Rice or starch powder. 

One-half pound borax. 

One-quarter pound mustard. 

One package Robinson's Prepared Barley. 

Milk sugar. 

Lime water. 

Toothpicks. 

Small bag of salt. 

Bag of bran. 

Pad for scale. 

Tissue paper. 

Large size washable doll. 

Quilted padding, five yards, to make cheap mattress and pillow. 

Enameled cup or saucepan, with cover, one-half pint. 
Public Health Education. — The subject of proper education of the 
mothers in infant care varies with the type of locality. In country or 
rural districts where visiting nurses are not available, or may be seen only 
at widely separated intervals, pamphlets of instruction on infant care 
should be detailed and elaborate. It is permissible in such pamphlets 



694 CHILD HYGIENE 

to give positive instruction as to infant feeding*, with samples of the 
formulae. Jn communities where public health nurses are available, how- 
ever, pamphlets on infant care should consist only of broad principles of 
instruction. The details should be left to the public health nurse to carry 
to the individual family and should be suited to the individual case. It 
is probable, also, that in large cities at least 75 per cent, of the people 
who must be reached in order that public health education may be 
effective cannot be reached by the written word. They must have 
direct personal instruction. This may be brought to them (1) through 
the visiting nurse and (2), of course to a much less effective extent, 
through the young children of the family. This latter method, how- 
ever, should not be underestimated. The value of teaching school 
children the truths of hygiene and well-being and having these facts 
transmitted to the family has proved to be of great value. In the 
same way the teaching of young girls regarding the care of children is 
an excellent method of having such teaching carried to the real mother. 
Newspaper articles are mainly valuable for their general interest to 
the public, although in certain localities it has been found that weekly 
articles on different phases of baby care have a distinct value. This 
method has been tried out more consistently in New Zealand than 
anywhere else. In that country each newspaper publishes once a 
week a column under the general heading of "The Baby." Material 
for this column is furnished by the New Zealand Society for the Health 
of Women and Children, w T hich is a quasi-governmental organization. 
If printed pamphlets are used, emphasis should be placed upon the 
constructive rather than the destructive side. "Do's" have a far 
greater value than dont's. Effort should be made to tell the mothers 
how to take care of their babies rather than how to avoid doing what is 
wrong. 

Auxiliary Aids : Cooperation of Baby Welfare Organizations. — It must 
be recognized in the beginning that infant mortality is an exceed- 
ingly complex problem, therefore any public or private organization 
which in any way works for the welfare of the baby should work in 
close cooperation with the authorities that are endeavoring to lower 
the infant morbidity- and mortality-rates. In many cities there has 
been great duplication of effort, overlapping of work caused by this 
lack of cooperation. Health officers should consider that as public 
officials it is their duty to correlate the work of all private health 
organizations in the community. This in no way need interfere with 
the integrity or effective working of any institution. It simply 
affords a means whereby the full measure of cooperation may be 
obtained. 

It is necessary for the infant welfare nurse, as well as the child 
welfare nurse, to have an intimate knowledge of the facilities at their 
disposal. Quick results in obtaining material relief or in adjusting 
social problems are essential in reducing the baby death-rate. Such 
facilities, therefore, should be encouraged and extended and made use 
of by the health officer. 



CARE OF ABANDONED OR ILLEGITIMATE CHILDREN 695 

CARE OF ABANDONED OR ILLEGITIMATE CHILDREN. 

The high death-rate among babies born out of wedlock has already 
been mentioned. This probably accounts to a certain extent for the high 
death-rate occurring in institutions for foundling babies. These institu- 
tions also receive abandoned children born in wedlock who necessarily 
suffer much from the privations they have met with before being received 
into the institutions. Notwithstanding these two facts, however, the 
death-rate of institutions for foundling babies has remained so abnor- 
mally high that it has become a very definite factor in the infant death- 
rate and must be considered in any effort to reduce such a rate. 

It has been found that institutionalism, per se, has a serious effect 
upon the health of very young babies. The regularity of the life and 
the absence of the human and individual element in baby care seems 
to be the important factor. This point of view has received marked 
support because of the marked reduction in the death-rate as a result 
of taking these infants from the institutions and giving them out to 
board in private families. In order that this may be carried out safely, 
however, no woman should be allowed to board a child until she has 
received a permit therefor from the local board of health allowing her 
to do so. Before this permit is granted the woman and her surround- 
ings should be carefully inspected by a physician from the board of 
health, this report determining whether or not the permit should be 
granted. The following items may be looked for: 

1. Nature of the premises. 

2. Number of rooms. 

3. Number of persons in the family, including number of children 

and then ages. 

4. Number of boarders (adults and children). 

5. If any infectious diseases are present. 

6. Sanitary condition of the house and of the rooms occupied by 

applicant. 

7. Light and ventilation of rooms. 

S. Personal appearance and health of applicant. 
9. Condition of child (if already boarded). 

10. Character of feeding (breast or artificial). 

11. In case the applicant intends to breast-feed the child, the inspec- 

tor notes : 

(a) Name of applicant's last child. 

(b) Date and place of its birth. 

(c) Name and address of physician or midwife in attendance 

at the birth. 

(d) Date, place and cause of child's death. 

(e) Names and addresses of the attending physician and 

undertaker. 

12. Race, religion and color of applicant. 

13. Grade of home, based on sanitation and surroundings. 

14. Class of home, whether suited for breast-fed or bottle-fed infants, 

children under two vears or children from two to six vears. 



fiOO CHILD HYGIENE 

When a boarded-out baby is being breast-fed, the main points to be 
considered are the health and natural ability of the foster mother. 
If the baby is to be artificially fed, however, more stringent attention 
must be paid to the sanitary surroundings. Such babies must be 
carefully supervised in order that there may be no abuse. The follow- 
ing regulations are advised : 

REGULATIONS GOVERNING THE BOARD AND CARE OF CHILDREN. 

Regulation 1. — Applicant must specify whether she intends to act as 
wet or dry nurse. The applicant for a permit must specify whether 
she intends to act as a wet nurse or as a dry nurse. 

Regulation 2. — Quality and quantity of milk to be adequate and 
suitable. A permit for wet nursing will not be issued unless the 
quantity of milk is adequate and the quality of milk is suitable. If at 
any time after the issuance of the permit the quantity of the milk is 
inadequate or the quality of milk is unsuitable, such permit will be 
immediately revoked. 

Regulation 3. — Personal attention required. The person to whom a 
permit is issued must give personal attention to the proper feeding, 
care and hygiene of the child or children entrusted to her care and 
control. 

Regulation 4. — Children to be always attended. The child or 
children must never be left without an attendant. 

Regulation 5. — Rooms to be kept clean and sanitary. The rooms 
must be well ventilated, clean and sanitary and must be kept in an 
orderly and neat condition. 

Regulation 6. — Excess boarders forbidden. No greater number of 
children than the terms of the permit allow shall be received, boarded 
or kept. 

Regulation 7. — Notice of removal. It shall be the duty of any per- 
son to whom a permit has been granted to immediately notify the board 
of health in the event of removal to another address or to another 
apartment at the same address. 

Regulation 8. — Notice of illness. If the child is taken ill, the parent 
or the institution from which the child was obtained shall be imme- 
diately notified, and the child should be treated by a private physician 
or at a hospital or dispensary or the board of health notified imme- 
diately of such illness. 

Regulation 9. — Care of sore eyes. If a child's eyes become sore, 
they should be treated by a private physician or at a hospital or dis- 
pensary or the board of health notified immediately of such fact. 

Regulation 10. — Permits. The permit is issued for the period of one 
year and may be revoked by the board of health at any time for viola- 
tion of any of these regulations. 

Regulation 11. — Register. Every person holding a permit to board 
and care for children must keep a register wherein he or she shall 
enter the names and ages of all such children, the names and residences 



SUPERVISION OF CHILD OF PRESCHOOL AGE 697 

of their parents as far as known, the time of the reception and discharge 
of such children and the reasons therefor, and also a correct register 
of the name and age of every child under the age of five years who is 
given out, adopted, taken away, or indentured from such place to or 
by anyone, together with the name and residence of the person so 
adopting, taking or indenturing such child, and shall cause a correct 
copy of such register to be sent to the board of health within forty- 
eight hours after such child is so given out, adopted, taken away, or 
indentured. Such register shall be supplied by the board of health 
to all such persons. 

Experience has shown that these babies boarded out in private homes 
have greater chances of life than those kept in institutions. Marked 
reduction in the death-rate has been shown in all instances coming 
under the writer's observation. 



SUPERVISION OF THE CHILD OF PRE-SCHOOL AGE. 

This has been the most neglected period of child life so far as public 
health is concerned. The reason probably lies in the difficulty with 
which these children can be reached. The birth certificate furnishes 
the point of attack for the work for the reduction of infant mortality 
and the schools furnish a ready clearing-house for health supervision 
of children of school age. There is no such easy means for the super- 
vision of the health of the child between two and five years of age. 

Within recent years special efforts have been made to see that these 
children receive the same health care as children of the younger and 
older ages. As an age group, health supervision at this time of life 
is particularly important. The contagious diseases of childhood are 
particularly noticeable during this period. In the registration area 
ninety-five out of every one hundred deaths from whooping-cough 
occurred under five years of age, eighty out of every one hundred deaths 
from measles, sixty-two per one hundred of all deaths from diphtheria 
and fifty-four per one hundred of all deaths from scarlet fever occurred 
in children under five years of age. Studies made of the occurrence of 
physical defects in children of this age group show that, with the possible 
exception of defective vision, the proportion of the various types of 
physical defects are much greater during the pre-school age than during 
later child life. The pre-school age, from the health point of view, 
bears the same relation to the health of the school child as the prenatal 
period bears to the child after birth. Adequate health supervision 
during infancy may provide the basis of good health so that the child 
may be more resistant to disease during the pre-school age period, but 
health supervision should not relax for this reason. If we carry our 
efforts in preventive medicine to their logical conclusion, the time to 
prevent the defects of school children is during their pre-school age 
period. The death-rate in this age group from all causes is extremely 
high, amounting in the registration area to one out of every four 



69S child hygiene 

deaths reported at all ages. For this reason the health program should 
include methods of supervision of the pre-school age child. 

Health Centers. -Baby health stations, as described previously, 
should be used as health centers for this age group. Children of this 
age should be canvassed for and registered. They may be referred 
by various agencies or the parents may be reached directly through 
publicity. Each child should be thoroughly examined and all physical 
defects and abnormalities noted. The cases should then be referred 
to the health center nurse whose duty it is to consult with the mother 
regarding the type of care the child needs. The nurse should also 
make as many home visits as may be necessary to see that her instruc- 
tions are carried out. Unfortunately, sanitary and hygienic conditions 
have a marked effect upon the children of this age group and efforts 
to reduce the death-rate under five are quite as important as the effort 
reduce the death-rate under one. 

Day Nurseries. — A direct method of supervision of the pre-school 
age child is offered by the day nursery. These institutions, which were 
first established in France about the middle of the last century, have 
not only a marked value in caring for the child but have great educa- 
tional value to the parent. Owing to the commercial possibilities in 
the day nursery, however, they should be carefully supervised from the 
health point of view. No such day nursery should be conducted in 
any town without a permit from the board of health and in accordance 
with the regulations of such board. The following regulations are 
recommended : 

REGULATIONS FOR DAT NURSERIES. 

Regulation 1. — Inspection of children on admission. Each child 
must be inspected on admission and if suspicious signs of contagious 
disease are noted the child must be placed in the isolation room and 
kept entirely apart from the other children and the board of health 
notified at once. 

Regulation 2. — Isolation room to be provided. An isolation room 
for cases of suspected contagious diseases shall be provided. 

Regulation 3. — Rooms to be above street level. All rooms devoted 
to nursery or kindergarten purposes shall be above the street level 
unless there is a cellar underneath the room so occupied. 

Regulation 4. — Premises to be kept clean. The premises shall at 
all times be kept in a clean and sanitary condition. Dry dusting or 
sweeping is prohibited. 

Regulation 5. — Ventilation, light and heat. Adequate ventilation, 
lighting and heating shall be provided. Except in extremely cold 
weather, adequate ventilation must be maintained by means of open 
windows. 

Regulation 6. — Ventilation for outer garments. A well ventilated 
room for children's outer garments shall be provided. In this room 
the clothing removed from the children in the morning must be placed. 






SUPERVISION OF CHILD OF PRESCHOOL AGE 699 

Regulation 7. — Air space. A minimum of two hundred cubic feet 
of air space for each child shall be provided. 

Regulation 8. — Floor space. Each iron bed or crib shall be placed 
so that there will be a space of two feet on all sides except where the 
head or sides of a bed or crib may touch the wall. 

Regulation 9. — Wire springs to be used; mattresses prohibited. 
Woven iron springs shall be provided, over which a folded blanket, 
protected by rubber or oilcloth sheeting, must be placed. Mattresses 
are not allowed. 

Regulation 10. — Use of common wash clothes, etc., prohibited. The 
use of common wash cloths, towels, combs and hair brushes is pro- 
hibited. 

Regulation 11. — Diapers to be washed. All diapers that have 
become soiled during the day shall be immediately placed in water and 
thereafter thoroughly washed and boiled. No diapers in an unclean 
condition shall be removed from the premises. 

Regulation 12. — Over-aprons to be provided. Unless the clothing 
worn by a child is thoroughly clean on admission, a suitable over-apron 
(the property of the day nursery) shall be worn through the day, and 
each individual apron shall be marked for identification, unless a clean 
apron is provided daily. 

Regulation 13. — Care of milk, etc. Adequate care must be taken 
of the milk, bottles and nipples used in infant feeding. 

Regulation 14. — Excess admissions forbidden. No more children 
shall be admitted daily than are allowed by the permit of the board of 
health. 

Regulation 15. — Physician to be attached to nursery. Each day 
nursery shall have attached thereto a regular physician of its selection, 
duly licensed under the laws of the State, and in good professional 
standing, and immediately upon the appointment of said physician 
the day nursery shall notify the board of health of the name and 
address of said physician. 

It shall be the duty of such physician : 

(a) To make a systematic examination of every regularly attending 
child at least twice a month, said examinations to be made at least 
two weeks apart. 

(b) To examine each child applying for admission and if suspicious 
signs of infectious disease are noted, to have such child placed in the 
isolation room, separate and apart from other children, and immediately 
notify the board of healthy or if such child is found free from infectious 
disease, to issue a certificate to that effect and deliver same to the 
matron in charge of the nursery. 

To take a vaginal smear from each female child applying for admis- 
sion where there is discharge from the vagina. This smear should be 
sent to the board of health for examination and a certificate of admis- 
sion as provided in section (6) of this regulation should not be issued 
unless the result of the examination of such smear is negative. 



700 CHILD HYGIENE 

Regulation 16. —Duties of matron. It shall be the duty of the 
matron in charge of each day nursery: 

(a) To have on file, in the office of the nursery, an original certificate 
of health, signed by the nursery physician, for each child that is a 
regular attendant. 

(6) To have on file, in the office of the nursery, a record that each 
child regularly attending has been examined by the nursery physician 
at least twice a month, the said examinations being not less than two 
weeks apart. 

(c) To prevent the admission to the nursery of children who have 
not been examined by the nursery physician and to whom a certificate 
to the effect that they are free from infectious disease has not been 
issued. 

(d) To notify the board of health and the nursery physician immedi- 
ately, by telephone, of any suspicious rash or illness which appears 
among the children, during the absence of the nursery physician, and 
to isolate any child or children so affected in the isolation room. 

(e) To make daily inquiry of each mother or other person bringing 
the child as to whether or not any sickness exists in the child's home, 
and if any suspicion is aroused as to the possibility of such home sick- 
ness being of an infectious nature, the child shall be excluded and the 
board of health notified, and such exclusion shall continue until a 
certificate of the board of health is furnished to the effect that the 
premises referred to are free from infectious disease. 

(J) To require that every certificate of health for a female child 
shall not be considered complete unless attached thereto is a certificate 
of the board of health to the effect that the examination of the vaginal 
smear is negative. 

(g) To exclude any female child who has been shown by examina- 
tion of a vaginal smear to be affected with gonorrheal vaginitis unless 
accompanied by a certificate of the board of health to the effect that 
two smears taken on successive days have shown negative results. 

(h) To enforce all rules and regulations of the board of health for the 
conduct of day nurseries in so far as they relate to heating, lighting, 
ventilation, cleanliness and general sanitary condition of the day 
nursery under her charge, and the care and maintenance of the attend- 
ing children and their clothing, and the character and method of 
preservation of food. 

SCHOOL MEDICAL INSPECTION AND HYGIENE. 

History of School Medical Inspection. — The first instance of health 
supervision of school children occurred in France where, by the law of 
1833 and a Royal Ordinance of 1837, the school authorities were 
charged with the duty of providing sanitary condition of school 
premises and supervision of the health of the children. Very little 
work was undertaken in this regard and it was not until 1842 that the 
government issued a decree that all public schools in Paris must be 






SCHOOL MEDICAL IXSPECTIOX AXD HYGIEXE 701 

inspected by physicians. School medical inspection as it is in effect 
at the present time did not actually commence in Paris until 1897. 
Germany was the second country to institute a system of health super- 
vision of school children. This occurred in 1867 in Dresden, where 
annual tests of vision were required. Real school medical inspection 
in that country, however, began at Frankfort-on-Main in 1889. The 
dates of installation of this system in the indicated countries are as 
follows : 

France 1833 

Germany 1867 

Sweden' 1868 

Russia 1871 

Austria 1873 

Belgium 1874 

Egypt (Cairo) 1882 

" Norway 1885 

Argentine Republic and Chile 1888 

England (London) 1891 

United States 1894 

Mexico 1896 

Japan 1898 

Bulgaria 1904 

Australia 1906 

Tasmania - 1906 

Canada (Montreal) 1906 

In the United States, school medical inspection was started in the 
City of Boston in 1894 where, on account of an epidemic of diphtheria, 
it was found necessary to send physicians into the public schools to 
limit the spread of the infection. While in Europe the general health 
of the child wa& taken as the basis for the first systems of school 
medical inspection, in the United States the desire to limit the spread 
of infectious disease was the compelling motive. Philadelphia was the 
second city to institute this system — in 1895 — while New York City 
began its work in 1897. At the present time systems of school medical 
inspection are in effect generally throughout the United States. 
"Twelve States have mandatory laws which make school medical inspec- 
tion obligatory in the various cities and towns. These States are 
Massachusetts, District of Columbia, New Jersey, Colorado, Maine, 
Minnesota, Louisiana. New York, Pennsylvania, Rhode Island, Utah 
and West Virginia. Twenty-two States have permissive laws, author- 
izing any towns to assign school physicians if they choose to do so. 
In addition to these, a considerable number of cities and towns carry 
on a system of school medical inspection with the authority of local 
ordinances or occasionally without any legislation. 

School Medical Inspection as Part of the Health Program. — All 
early systems of school medical inspection in this country were placed 
under the local health boards, with the distinct recognition that the 
health control of children is a health and not an educational matter. 
The matter of placing this work under either health or educational 
authorities is one which has received much attention for many years. 
In the United States, out of thirty-four States which have laws requiring 



702 CHILD HYGIENE 

or permitting the employment of medical inspectors, twenty-nine have 
the work definitely under the State board of health. In four it is under 
the State board of education, while in one State the two boards adminis- 
ter the work jointly. In general, a great proportion of the large cities 
have the work under the control of the State boards of health, while 
smaller towns and rural communities are more generally under the 
supervision of the educational authorities. The reason for this seems 
to be a local one. In large cities, health boards are usually well 
organized and have adequate machinery for carrying on so extensive 
a program as the health supervision of children of school age. In small 
towns and rural communities where the value of health work has not 
been properly recognized, the health officer is frequently a part-time 
employee, with no administrative machinery at his disposal. For this 
reason school boards, which are usually well organized even in the 
smallest places, have been in a position to initiate the work. School 
authorities, generally, take the point of view that the conservation of 
the health of the child is distinctly their responsibility and part of the 
general educational program. They also claim that as they have the 
buildings and the children under their immediate supervision, there 
would be less friction and greater efficiency if the health supervision 
were controlled by them. Health authorities generally view the prob- 
lem of child health as part of any coordinated program for the con- 
servation of the health of all persons in the community. As the age 
group under fifteen is potentially the best field for public health work 
and also the age group where immediate health measures are probably 
most needed because of the high mortality- and morbidity-rates, health 
boards should not be allowed to delegate this responsibility to any 
other authority. To assume that a health board can care for the 
health of the population under six years of age and then neglect such 
health measures until the individual has reached the age of fifteen 
implies a neglect of opportunity which should be condemned. Health 
work for children furnishes such an important part of the entire health 
propaganda that it should assume a position of first importance in the 
program of all health activities. In small towns, however, where 
health boards are unable to assume any responsibility except the most 
superficial control of contagious diseases, this work may be undertaken 
by boards of education. It must be kept in mind, however, that the 
average school is open only about one hundred and ninety days of the 
year and that during those one hundred and ninety days the child is 
under control of the school authorities for only five out of the twenty- 
four hours. Under school control, therefore, the child is without 
health supervision for the greater part of the year. 

School Medical Inspection Organization.— The health director or 
chief school medical inspector should devote his entire time to the 
service. The field inspector or school doctor may preferably give part 
time to the service and an average of three hours each school day should 
be required. While, theoretically, the school doctor may be assumed 
to offer better service if he has no other occupation, it has been found 



SCHOOL MEDICAL INSPECTION AND HYGIENE 703 

that with the small salaries paid for this position it is not possible to 
secure the type of service desired. Another and even more weighty 
objection is that exclusive work of this kind, without the inspiration 
afforded by general outside medical work, tends toward a narrowing 
of interests and routine work. The full-time health director should 
be paid a salary of from S3000 to S5000 a year, according to the 
population of the community. The school inspectors' salaries show a 
wide variation in different localities, but from $80 to S100 per month 
should be a minimum standard. Nurses' salaries are at present at 
too low an average, seventy-five dollars or less a month being the 
accepted rate. The work of the school nurses has broadened immeas- 
urably since they were first employed and while the present rate may 
be adequate for small towns and rural districts, a minimum salary of 
one hundred dollars a month should be established for cities. 

The ideal system would provide one physician fcr each three to four 
thousand children and one nurse to each twenty-five hundred to three 
thousand children. Such ideal conditions, however, can be found in 
but few places at the present time and the ratio of from five to nine, 
thousand children to each physician and from three to five thousand 
children to each nurse is more commonly encountered. 

Types of School Medical Inspection.— Four types of school medical 
inspection are recognized: 

(a) Those using physicians alone. 

(b) Those using physicians and nurses. 

(c) Those using nurses alone. 

(d) General supervision by teachers. 

(a) The employment of a school physician without a nurse is of 
doubtful value as the results of such procedure are usually only statisti- 
cal and lack of adequate follow-up work usually results in very little 
benefit to the children. 

(b) In systems using both physicians and nurses, the physicians 
are generally used for the diagnosis of contagious diseases and the 
physical examination of the children, the nurses carrying out routine 
inspection in the classroom, assisting the physicians and being respon- 
sible for the follow-up work in the homes to see that the physical 
defects are corrected. Any of these functions may be delegated to 
either physician or nurse. It has been found entirely feasible in New 
York City to have the nurse do all of the early detection of symptoms 
of contagious diseases, the reason for this being that nurses are trained 
to detect symptoms and the value of school supervision of infectious 
diseases lies in their early detection and exclusion from school rather 
than waiting until a final diagnosis can be made. 

(c) Particularly in small communities, it is possible to employ a 
nurse without a physician. This nurse, acting in close cooperation 
with the teacher, is not only able to detect the early symptoms of 
contagious diseases but also it is possible for her to determine those 
children who are apparently suffering from physical defects. Such 
children should be referred to their private physicians for diagnosis 



704 CHILD HYGIENE 

and treatment. If it is possible to employ only one person in any 
system of school medical inspection, this one person should be a nurse. 

(d) In any assignment of forces, the teacher must be considered as a 
valuable adjunct. Her close contact with the children makes her the 
first line of defense in the discovery of abnormal health conditions and 
she may readily be instructed in the methods of detecting defects of 
sight, hearing, teeth or nasopharynx, as well as nervous, orthopedic 
or nutritional disorders. She must be relied upon in all instances to 
detect the earliest symptoms of illness which may prove to be of infec- 
tious origin and, in rural communities, where the visits of the school 
doctor and nurse are made at infrequent intervals, she will prove of 
great assistance in making periodic health surveys, both of the school 
and its surroundings and of the pupils. 

Routine of School Medical Inspection. — The general routine of the 
school medical inspection system must vary in accordance with the 
number of children to be supervised, the distances between schools 
and the size of the medical and nursing staffs. The following outline 
is recommended and should be followed as closely as possible : 

1. Sanitary survey of school building, surroundings and equipment 
at the beginning of each term. 

2. Yearly testing of vision and hearing of all pupils (by nurse or 
teacher). 

3. Daily inspection of all pupils in each classroom by class teacher, 
this inspection to take place at the opening of the morning session, the 
teacher to refer at once to the doctor's room all children who show any 
symptoms of any illness or physical abnormality. 

4. Periodic lectures to teachers (at least once a month) to be given 
by the school doctor or nurse on the topic of school or child hygiene 
and the early detection of symptoms of illness. 

5. Daily visit to each school by the doctor or nurse. At this visit 
the following children should be examined and appropriate action 
taken: 

(a) All children referred by teachers as showing symptoms of illness 
or physical defects : 

(b) All children who have been previously excluded from school 
attendance. 

(c) All children who have returned to school after any unexplained 
absence. 

6. Routine inspection of all pupils in the school, at the beginning of 
each term, by the school doctor and once each month thereafter by the 
school nurse. 

7. Physical examination of each child in the following order: 

(a) Children entering school for the first time. 

(b) Children referred by the nurse or teacher. 

(c) All other children in the school, proceeding grade by grade. 

8. Regular visits by the school nurse to : 

(a) Treat all cases of mild forms of contagious eye and skin diseases, 
allowing the children to remain in school attendance while under 
treatment. 



SCHOOL MEDICAL INSPECTION AND HYGIENE 705 

(6) Treat minor injuries by means of first aid, such cases to be there- 
after referred to their parents to provide the necessary care. 

(c) Confer with teachers regarding health conditions of the children 
and the readjustment of school surroundings. 

9. Visits by the nurse to the homes of children suffering from physical 
defects whose parents have neglected to provide proper care. At these 
visits the nurse should instruct and advise parents regarding the need 
of treatment and the hygiene of the home and of the child. 

Contagious Diseases. — The control of contagious diseases in school 
children includes proper supervision of the hygiene of the school and 
its maintenance as well as the detection of symptoms at the earliest 
possible moment. 

The school building and its maintenance deserve first consideration. 
Classrooms should be large enough to provide at least three hundred 
cubic feet of air space for each pupil. Each room should have direct 
sunlight at some period of the school day. Each child should have an 
individual desk with aisles at least two feet wide between the rows. 
Dry sweeping and dusting must be prohibited and proper oil dressing 
provided for the floors. Pencils should be individual and collected 
at the end of each day, in separate stout manila envelopes, marked with 
the name of the child, so that distribution may be made each morning. 
Lastly, and most important, free ventilation with the provision of air 
at the right temperature and degree of humidity is imperative. 

In the school building, cloakrooms with individual ventilated lockers 
or hooks placed at wide enough intervals so that the children's outer 
garments shall not be in contact, are essential. The further installa- 
tion of drinking fountains or the use of the individual drinking cup, the 
elimination of the common towel and the provision of adequate and 
cleanly toilet and washing facilities will all provide the needed surety 
of the first line of defense against the spread of infection in the school. 

The main control for the prevention of the spread of communicable 
diseases in schools is dependent upon the system of school medical 
inspection. It is evident that such a system, to be effective, must 
rely upon such an early detection of symptoms which may indicate the 
onset of a communicable disease that the child may be excluded from 
school attendance and properly isolated at home before he has had an 
opportunity of infecting others. In other words the child must be 
excluded "on suspicion." If we wait until an accurate diagnosis can 
be made, the harm has already been done. 

Each day each school should receive a printed list of all cases of 
communicable diseases reported to the Department of Health on the 
previous day. At the opening of the school session, this list, with a 
special blank book, should be sent to each classroom, where the teacher 
should enter the name of each pupil in the class who is noted on the list 
or who i? a member of the family of any patient. Such children should 
be excluded from school at once to await the action of the division of 
contagious diseases of the department of health. The book is then 
returned to the school nurse, who reports each day to the school inspec- 
45 



706 CHILD HYGIENE 

tor where two or more cases of any one communicable disease have 
occurred in any one classroom. Thereafter, the inspector visits that 
class each morning, examining each child for any evidence of illness 
and excluding suspicious cases. If the disease is diphtheria, cultures 
are taken from the throats of all pupils and all cases showing the 
presence of the diphtheria bacillus are excluded. 

The teachers should be instructed to send to the doctor's room, as 
soon as the classes assemble, every child who shows any evidence of 
illness in any form. The doctor or nurse should examine these children 
in a room set apart for this purpose. At this time any child who shows 
any symptoms which might indicate the development of a communi- 
cable disease should be excluded from school attendance. Cultures are 
taken in every case of sore-throat and the child excluded. Within 
tw^enty-four hours the child should be visited at his home by a medical 
inspector, who makes the diagnosis, either isolating the case and 
transferring it to the supervision of the division of contagious diseases 
which thereupon assumes control, or, if no communicable disease has 
developed, allowing the child to return to school. In New York City 
about 80 per cent, of the excluded children are found to have true cases 
of communicable diseases. The loss of one day's schooling for the 
remaining 20 per cent, is of small consequence when compared with the 
effectiveness of this early exclusion. 

The early detection of tuberculosis results from observation of 
children who have been losing weight, appear flushed or hectic, with or 
without an accompanying cough, and who are designated as suspicious 
cases by the school doctor as a result of his regular physical examination. 

Schools should not be closed during the progress of an epidemic of 
infectious disease. School contact instances of infection are rare. 
If the system of school medical inspection is at all adequate, the pres- 
ence of the children in the classroom where they can be systematically 
observed for symptoms of approaching illness offers a far greater degree 
of safety to the child and protection to the other children than can be 
obtained by allowing the children to be in their homes or on the street 
in indiscriminate contact with other children. It also offers an oppor- 
tunity of instituting early isolation of any cases of infectious diseases, 
thus limiting the spread of the infection, a procedure which is impossible 
if children are at home or on the streets and utterly without supervision. 

Contagious Eye and Skin Diseases.- — It has been amply demonstrated 
that the majority of children affected with contagious eye and skin 
diseases may be kept in school without danger to the other children 
as long as they continue under regular treatment. Each such case 
found should be given a notice to be taken to the parent or guardian,' 
informing him that the child has a contagious disease of the skin or 
eyes and that unless such condition receives prompt treatment the 
child will be excluded from school, with the further advice that the 
child be taken, with this notice, to the family physician for treatment. 

If on the morning of the following day it is evident that the child 
has obtained treatment, he should be allowed to remain in school but 



SCHOOL MEDICAL INSPECTION AND HYGIENE 707 

required to report to the nurse at regular intervals and unless evidence 
of continued treatment is shown should be excluded from school attend- 
ance until the disease has disappeared. 

Where no treatment has been obtained, the following method is 
advised : 

(a) Cases to be excluded : 

1. Contagious eye diseases with symptoms of acute inflammation 
or discharge. 

2. Contagious skin diseases with extensive lesions. 

3. Pediculosis with live pediculi. 

(b) Cases which may be allowed to attend school while under 
treatment by a private physician, dispensary or the school nurse: 

1. Acute conjunctivitis. 

2. Pediculosis with no live pediculi. 

3. Skin diseases, including ringworm of scalp, face or body, scabies, 
favus, impetigo, molluscum contagiosum. 

4. Cases of trachoma should be instructed as to the necessity of 
treatment and required to report to the nurse at regular intervals to 
see that such treatment is maintained. However, they should never 
be treated by the nurse. 

Circulars giving instructions as to methods of home treatment of 
pediculosis and also as to the care needed in cases of trachoma should 
be prepared and sent to the family of each child affected. 

The methods of procedure to be followed by the school nurse in treat- 
ment of eye and skin diseases may be readily outlined by the health 
board and should be followed in each instance. The following are 
suggested : 

Methods of Treatment of Contagious Eye and Skin Diseases to be 
Employed by the School Nurse. 

Favus; Ringworm of Scalp. — Mild Cases. — Scrub with tincture of 
green soap and cover with flexible collodion. 

Severe Cases. — Scrub with tincture of green soap, paint with tincture 
of iodine and cover with flexible collodion. 

Ringworm of Face and Body.—. Wash with tincture of green soap and 
cover with flexible collodion. 

Scabies. — Wash with tincture of green soap and apply sulphur 
ointment. 

Impetigo. — Remove crusts with tincture of green soap and apply 
white precipitate ointment (ammon. hydrarg.). 

Molluscum Contagiosum. — Express contents. Apply tincture of 
iodine on cotton-covered toothpick. 

Conjunctivitis. — Irrigate with solution of boric acid. 

Pediculosis. — Saturate scalp and hair with mixture of equal parts 
kerosene and sweet oil. Next day wash with a solution of potassium 
carbonate (one teaspoonful to one quart of water), followed by soap and 
water. 



A 



708 CHILD HYGIENE 

In general the principle of these treatments is protection of the 
affected so that the infectious material may not be transmitted. 

In New York City this method of care has reduced the exclusions for 
this cause from 57,000 in 1903 to less than 5000 in 1914, and no instance 
of spread of infection in the schools has occurred during that time. 

Routine Inspection. — x\t the beginning of each term the medical 
inspector should make a routine classroom inspection of each child in 
the school. Thereafter the nurse should make the routine class 
inspection at least once a month, following the same procedure. 

The inspector should stand with his back toward the light from a 
window and the children should pass in line in front of him. The 
condition of the eyelids, throat, skin and hair of each pupil must be 
observed. The inspector or nurse should not touch the child but the 
latter must be instructed to pull down the eyelids, open the mouth, 
show the hands and, in the case of girls, lift up the back hair. Wooden 
tongue depressors should be furnished and a separate one used for each 
child when such use is indicated. 

Whenever a child shows symptoms of any diseased condition, that 
fact should be noted and the child ordered to report to the doctor's 
office for more careful observation. When a child is found to be 
affected with any form of physical defect, a complete physical exami- 
nation should be made at the earliest possible opportunity. 

Emergency Treatment. — Either the inspector or the nurse should 
treat all emergency cases as a matter of first aid and all such cases 
should thereafter be referred to the parents for reference to the family 
physician for future care. Failure to observe this rule may lead to 
unpleasant consequences for the physician and nurse on the ground of 
interference with the practice of a private physician or it may happen 
that the city or town authorities may be held responsible for what the 
parents consider to be improper practice. 



EXAMINATION OF CHILDREN FOR PHYSICAL DEFECTS. 

Extent of Physical Defects in Children of School Age.— It has been 
estimated by Dr. Thomas D. Wood, Professor of Physical Education 
of Columbia University, that there are approximately twenty million 
school children in the United States at the present time. He states 
that from \\ to 2 per cent., or from 300,000 to 400,000, of these have 
organic heart disease; probably 5 per cent., or 1,000,000, have now or 
have had disease of the lungs; about 5 per cent., or 1,000,000, have 
spinal curvature, flat-feet or some other mild deformity serious enough 
to interfere with health; over 5 per cent., or 1,000,000, have defective 
hearing; about 25 per cent., or 5,000,000, have defective vision; about 
25 per cent., or 5,000,000, are suffering from malnutrition; over 30 
per cent., or 6,000,000, have enlarged tonsils, adenoids or enlarged 
cervical glands; from 50 per cent, to 95 per cent, have defective teeth. 

Altogether, about 75 per cent., or 15,000,000 school children in this 



EXAMINATION OF CHILDREN FOR PHYSICAL DEFECTS 709 

country, arc suffering from physical defects, almost all of which are 
preventable and which, to a certain extent, can be corrected. 

Standards of Health in the Child of Rural and Urban Communities. — 
Wood has also made a study in eight States which shows that, in general, 
the occurrence of physical defects in country children is from 15 per 
cent, to 25 per cent, greater than among city children. It is probable 
that this sharp contrast did not exist several years ago, but at the 
present time systems of school medical inspection are so universal in 
cities that it would seem logical to assume that the prevalence of 
physical defects would be less noticeable in large centers of population 
than in places where little or no effort has been made to either prevent 
or correct them. The actual effect of city or rural life on the child can 
hardly be determined in a study of this kind. It would seem to show, 
however, that the general environment of the child, that is, whether 
it is rural or urban, has less importance than has been thought in the 
past, and that the predisposing causes of these physical defects or 
abnormalities are matters which concern the immediate surroundings 
or environment of the child and pertain more particularly to conditions 
in homes and in schools. 

Frequency of Physical Examinations. — In a number of States laws 
have been passed making mandatory the physical examination of each 
school child each year. A careful survey of the administration of these 
laws fails to reveal that the results hoped for are being secured. These 
annual physical examinations are necessarily costly and the tendency 
therefore is to substitute a superficial inspection for what is supposed 
to be a careful physical examination. It is of far greater value to have 
a proper physical examination carried on two or three times during 
the school life of the child, supplemented by regular classroom inspec- 
tions at frequent intervals, than to depend entirely upon an annual 
inspection, even though it may be called a physical examination. In 
Em-ope, generally, children are examined three times during their school 
life: First, on entrance to school, second, in the intermediate grades, 
and third, just before leaving school. 

Studies of the occurrence of physical defects in school children show 
that, with the exception of defective vision, they are in inverse ratio 
to the age of the child. Physical examination, therefore, of children 
entering school for the first time is of the utmost importance. This 
should be thorough and complete and, wherever such course is possible, 
the child should have its clothes removed, at least as far as the waist- 
line, for the purpose of this examination. In these cases it is also 
desirable that the follow-up work in the homes should be 100 per cent, 
efficient. If these children, on entering school, could be placed in 
proper physical condition, the later occurrence of a considerable 
proportion of physical defects might be discounted. Emergency cases 
or those occurring later in school life can usually be apprehended 
during the course of the regular classroom inspection. 

Physical Defects. — Statistics regarding the prevalence of physical 
defects among school children are open to criticism because of the 



710 CHILD HYGIENE 

lack of methods of standardization of the manner in which examina- 
tions are made and records kept. The following is offered as a guide: 
Method of Physical Examination. — Each child must be carefully 
examined to determine the presence of any of the following defects: 

1. Defective Vision. — The Snellen test-card should be used, with 
separate examination and record of visual acuity of each eye. A paper 
or card should be used to cover the eye not being tested. 

2. Defective Hearing. — Either an acumeter or the watch or whispered 
voice test at a standard distance may be used. 

3. Defective Nasal Breathing. ^The nasal passages must be cleared 
and the passage of air through each nostril tested by pressure occlusion 
of the opposite nostril. Evidence of mouth breathing must be differ- 
entiated between (a) habit and (6) obstruction of the nasal passages. 

4. Hypertrophied Tonsils. — Visual examination should be made with 
the use of a separate tongue depressor for each child. 

5. Defective Teeth. — Visual examination should be made with refer- 
ence to whether the primary or permanent teeth are affected and the 
extent of the defects. 

6. Defective Nutrition. — It should be determined whether the con- 
dition is found alone or dependent upon other physical defects. The 
two following methods of determining the degree of undernourishment 
may be used as standards of measurement. 

(a) Height and weight in relation to age, as shown by table on pages 
712 and 713. 

(6) The Dunfermline scale, as follows: 

(1) " Excellent" means the nutrition of a healthy child of good social 
standing. 

(2) Children whose nutrition falls just short of this standard are 
"good." 

(3) Children '* requiring supervision" are on the borderland of 
serious impairment. 

(4) Children "requiring medical treatment" are those whose nutri- 
tion is seriously impaired. 

7. Cardiac Disease. — In the case of boys, the examination for this 
condition should be made with a stethoscope over the bare skin. In 
the case of girls, the stethoscope must be used over the clothing unless 
the parent is present and consents to its removal or the written consent 
of the parent has been obtained for the removal of any part of the 
clothing. General objective symptoms should be noted. 

8. Pulmonary Disease. — The lungs should be examined with a 
stethoscope. In the case of boys, the examination should be made 
over the bare skin. In the case of girls, the stethoscope must be used 
over the clothing unless the parent is present and consents to its 
removal or the written consent of the parent has been obtained for the 
removal of any part of the clothing. General objective symptoms should 
be noted and if any doubt exists as to the diagnosis the case should be 
referred for more extended diagnosis as hereinbefore described. 

9. Orthopedic Defects. — The character of the defect should be noted. 



EXAMINATION OF CHILDREN FOR PHYSICAL DEFECTS 7ll 

10. Nervous Diseases. — The type of the nervous affection should be 
noted . 

11. Defective Mentality. — No particular test need be given but when, 
in the opinion of the inspector, the mentality of the child is considered 
defective, a special note to that effect should be made to the teacher 
with the recommendation that the child be referred to the Inspector 
of Ungraded Classes of the Department of Education. 

Follow-up Visits by Nurses. — Whenever a child is found to have a 
physical defect, a complete record of the physical examination should 
be made on a special form which is given to the nurse for follow-up 
work. This note should be made in duplicate, upon a form of record 
card which is to remain in school and be attached to the child's school 
record. This physical examination card should be transferred with the 
child and space should be provided for future examinations so that the 
complete history of the child may be available at any time. . 

If, at the end of three days, no notice has been received from the 
parent that the child is under medical care, and if the child shows no 
evidence of such care, the parent should be asked to call at the school 
and see the school doctor or nurse, who should explain to the parent 
the nature of the defect and the need of treatment. 

These school consultations may be made most effective and should 
generally be held on Saturday mornings in the school buildings. By 
means of them the doctor and nurse will often be able to see from forty 
to fifty parents in three hours, the time that would be spent in making 
from ten to twelve home calls. 

If the parent fails to come to the school within three days, and if it 
is evident that no satisfactory treatment has been obtained for the 
child within the following ten days, the nurse should visit the home and 
explain to the parent the environmental and "personal changes in 
hygiene and individual treatment necessary to keep the child in good 
health. In this work the greatest tact is required. It is educational 
health work of the highest type. The public health nurse is not a 
person who cares for the sick; she is a teacher of health and the 
greater part of her endeavors should be concentrated upon instilling 
the principles of proper and wholesome living into the minds of the 
people with whom she comes into contact in her official capacity. 

The first visit of the nurse to any home should be only to establish 
cordial relations and to assure the parents that her purpose is helpful. 
Later and repeated visits should be made to the extent necessary to 
see that the children are receiving the benefit of her instruction and 
receiving proper care. It is a legitimate part of the school nurse's 
work to take children to dispensaries for treatment if the parents are 
so occupied that they cannot spend the time for this purpose. In 
such instances, however, it is important that the nurse obtain from 
the parent a form of release of responsibility. This should be a card 
containing a statement from the parent in the form of a request to the 
nurse to take the child to a private physician or to a dispensary for 
treatment. This must be signed by one or both parents. Failure to 



712 



CHILD HYGIENE 



observe this simple requirement may lead to serious complications or 
even legal action. 

Records. — The type of cards to be used in school medical inspection 
will necessarily vary with the extent of the work to be performed. 
The following are suggested as essential, even in simple systems: 

1. Card notices to parents of the existence of contagious diseases 
or physical defects. 

2. Circulars of instruction on the care of the health of children. 

3. Health record of the child, to include : 

(a) Data regarding date of birth and nationality of parents. 

(b) Previous history, to include infectious diseases, date of vaccina- 
tion and other health data. 

(c) Record of all illnesses occurring while the child is in school. 

(d) Record of all defects, together with measures taken to correct 
them. 

4. Record of daily work performed by the inspector or nurse, to be 
forwarded to the central office for tabulation. Weekly reports may be 
used for this purpose. 



RIGHT HEIGHT AND WEIGHT FOR BOYS. 

(Tables prepared by Dr. Thomas D. Wood for the Child Health Organization.) 



Height, 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


1G 


17 


18 


in. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


39 


35 




























40 


37 


38 


























41 


39 


40 


























42 


41 


42 




















. 






43 


43 


44 


44 
























44 


45 


45 


46 
























45 




47 


47 


48 






















46 




49 


50 


50 






















47 






51 


52 


52 




















48 






53 


54 


55 




















49 








55 


56 


57 


















50 








58 


59 


59 


















51 








60 


61 


62 


62 














52 










64 


65 


65 














53 










67 


68 


68 


68 












54 










70 


71 


71 


72 












55 












74 


75 


76 


76 










56 












77 


79 


79 


80 










57 














81 


82 


83 


84 








58 














84 


85 


87 


88 








59 
















88 


89 


91 


92 






60 
















90 


92 


94 


95 






61 


















97 


99 


100 


101 




62 


















100 


102 


104 


105 




63 


















104 


106 


108 


109 


110 




64 




















112 


113 


115 


117 


120 


65 




















118 


119 


121 


122 


123 


66 






















123 


124 


125 


127 


67 






















125 


126 


127 


131 


68 






















130 


131 


133 


136 


69 
























134 


136 


139 


70 








.. 


.. 


.. 












136 


140 143 


71 






















" 




142 1 145 



EXAMINATION OF CHILDREN FOR PHYSICAL DEFECTS 713 



ABOUT WHAT A BOY SHOULD GAIN EACH MONTH. 

Age. Ounces. 

5 to 8 years 6 

8 to 12 " 8 

12 to 16 " 16 

16 to 18 " 8 



RIGHT HEIGHT AND WEIGHT FOR GIRLS. 



Height, 


! 
5 6 7 


8 8 


10 


11 1 


2 13 


14 


15 


16 


17 


18 


in. yrs. yrs. yrs- yrs. ; yrs. yrs. 

i 


yrs. y 


-s. yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


yrs. 


39 i 


54 






















40 : 


55 37 






















41 { 


59 39 






















42 . i 


U 42 4 


2 




















43 i i 


13 44 4 


4 






















44 


15 46 4 


6 






















45 


47 4 


7 


47 




















46 


48 4 


9 


50 




















47 


. .. 5 





51 5 


3 


















48 


. . . 5 


2 


53 5 


4 


















49 






55 5 


6 


57 


















50 






57 5 


9 


60 


















51 






6 


1 


62 


63 
















52 








6 


5 


66 


67 
















53 












68 


68 


( 


19 












54 












70 


71 




r l 












55 














72 




'3 74 












56 




• 1 










76 




n 77 


79 










57 


. . . . 


1 














19 82 


85 










58 
















I 


55 88 


93 


96 








59 




















92 


95 


100 


105 






60 


... 


















97 


99 


103 


107 


109 




61 


. 1 .. . 


• ! 
















99 


102 


105 


109 


111 




62 


I 


















. 


105 


107 


111 


113 


116 


63 


















. .. 


107 


110 


113 


115 


117 


64 


























114 


117 


119 


121 


65 

i 


.. . 

1 l 




















• 1 •• 






121 


123 


125 



ABOUT WHAT 
Age. 
5 to 8 j'ears 
8 to 11 
11 to 14 
14 to 16 
16 to 18 



A GIRL SHOULD GAIN EACH MONTH. 



Ounces. 



5. A tabulation sheet, to be kept in each school, showing the number 
of physical examinations made and the number and character of 
physical defects found, together with the results of treatment obtained. 

Other forms of reports will naturally suggest themselves and the 
standard types used in Philadelphia and New York City are recom- 
mended. 

Hygiene of the Child. — The relation of height and weight to the age 
of the child may be taken as the best index we have of its growth and 
development. The accompanying table, prepared by the Child Health 
Organization of New York City, may be considered a standard: 



714 CHILD HYGIENE 

In considering this table, allowance must be made for racial charac- 
teristics. Certain race groups, notably the Italians, are naturally 
small, while certain other Northern races, such as the Norwegian, often 
exceed the average for American children. 

The general hygiene of the child includes proper distribution of its 
hours of study, sleep and play, its bathing, clothing, diet, home sur- 
roundings and habits, w T ith individual adjustment in special cases. 

Study. — Our modern school curricula are overburdened and proper 
study time is rarely allowed within school hours. Children from five 
to seven years of age usually spend three hours a day in school and 
should have no home study. Children from seven to ten years of age 
may have five hours of school work with one hour of home study. 
Children from ten to twelve years old may have five hours of school 
work and one and a half hours of home study, while from twelve to 
fourteen years of age, five hours of school work with two hours of home 
study may be allowed. This home work should be done in the late 
afternoon or early evening, leaving the daylight hours for outdoor 
play. If artificial light must be used, it should preferably be a well 
trimmed oil lamp or low T -hung gas or electric burner with the light 
directly over the left shoulder or placed on a table at the left side. 
Such simple methods will often prevent eyestrain and obviate head- 
ache. The following table is suggested as a standard: 



Age, 
years. 


School 
hours. 


Hours for 
home 
study, 


Hours for 

meals and 

play. 


Hours for 
sleep. 


Bedtime. 


5 to 7 . . 


. . 3 


none 


10 


11 


7.30 


7 to 10 . . 


. . 5 


1 


8 


10| 


8.00 


to 12 . . 


. . 5 


1* 


8 


!H 


9.00 


.2 to 14 . . 


. . 5 


2 


8 


9 


10.00 



Standards of bathing, clothing and diet should be those recom- 
mended by authorities on pediatrics. It must be remembered that 
children learn more readily by the type of instruction which permits 
them to understand and act directly upon suggestions rather than by 
abstract study of the questions of hygiene itself. A successful pro- 
cedure has been to outline for children of different ages a time table 
covering their waking hours. These should start somewhat as follows : 

7 a.m. Throw back the bedclothes; rise; go to the open window 
and take ten deep breaths; close window; strip bed for airing and take 
sponge bath over the entire body, with tepid or cold water. 

7.15. Dress. 

7.30. Breakfast. 

8.00 
to 

8.30. Play. 

8.30. Start for school, etc. 

Such programs may be varied to suit individual needs but should 
always be simple, direct and concrete. 

Hygiene of the Home. — The sanitary and hygienic conditions of 
the child's environment are factors of importance in determining the 



EXAMINATION OF CHILDREN FOR PHYSICAL DEFECTS 715 

occurrence of physical defects. They may also be reflected in the 
lowered vitality of the child which predisposes toward the occurrence 
of certain types of contagious diseases. For these reasons the home 
surroundings of children should receive particular attention. 

The minimum air space which should be allowed for living apart- 
ments of any family are six hundred cubic feet for each adult and three 
hundred cubic feet for each child. Adequate ventilation, proper 
disposal of refuse, prevention of flies and general cleanliness are of the 
utmost importance, particularly with reference to the health of young 
children. 

In any community, the school inspector and nurse should be cogni- 
zant of the laws relating to building and housing conditions and should 
report all infractions of such laws to the proper officials. The main- 
tenance of the home in a decent and cleanly condition may become part 
of the work of the school nurse. It is her duty to so instruct the family 
that the children may be enabled to live in the best hygienic conditions, 
possible, considering the primary limitations of the home. 

Contrary to the general belief, it can often be shown that small 
shacks or shanties in country places are less hygienic and sanitary 
than tenements in a large city. Such living conditions undoubtedly 
have marked effect upon the health of the children who dwell therein. 
Home hygiene, which is closely related to the personal hygiene of the 
child, merits the serious attention of the school nurse, with reference 
to the prevention of the various diseases and defects of childhood. 

School Hygiene. — Practically everything that has to do with the 
construction of the schoolhouse and its furnishings and maintenance 
may affect in some degree the health of the child. School hygiene, in 
itself, therefore, must take up questions relative to everything that 
pertains to the location, furnishings and care of the school building. 

Location of School Buildings.— In cities, the general direction of the 
streets available for the location of school buildings may determine 
their orientation. There is, however, always a certain latitude in this 
regard, with particular reference to the location of the classrooms. 
Even on the most crow T ded streets it is usually within the power of the 
architect to determine whether the classrooms generally shall open 
upon the street or upon courts. Questions of proper light as well as 
exclusion of all unnecessary noise and street dust must be considered 
as they relate to the welfare of the child. In the country, such limita- 
tions ordinarily do not exist and it is generally possible to place the 
school buildings in any desirable position or location. In the country 
districts, however, it is necessary to consider the question of drainage 
and the proper location of the outhouses. For this reason, the site of 
the schoolhouse should, if possible, be on high ground with good drain- 
age. The water supply should be piped from a distance, if possible, 
but if it must be drawn from a nearby source, care should be taken to 
see that the outhouses are not placed in such a position that the sewage 
may be drained into any part of the w T ater supply. All other con- 
tamination of the water supply should be guarded against. 



710 CHILD HYGIENE 

If possible, schoolhouses should be built so that the classrooms face 
cast or west. Classrooms facing cast are preferable because they 
receive the early morning sunshine, which rarely enters the room later 
than ten o'clock. This affords the early flooding of the rooms with 
sunlight, with windows open, and disposes of the annoyance of cross- 
lights or bright sunshine during the remainder of the day. For the 
same reason, classrooms with western exposure are proper. Here the 
sunlight enters late in the day, but there are no annoying crosslights 
during the study hours. Rooms with southern exposure should never 
be used. Here the sunlight comes into the room during the greater 
part of the day and the light is difficult to control. Rooms with 
northern exposure have practically no sunlight and are undesirable for 
that reason. 

Size of Classrooms. — The classroom where the child spends at least 
four-fifths of his time while in school has a most intimate relation 
to health. Generally speaking, classrooms in the United States are 
too small for the number of children who are placed therein. The 
standard and ideal classroom depends upon several factors: 

Length. — Length of a classroom is determined by the distance that 
the ordinary speaking voice of the teacher will carry so that the child 
in the last row may hear distinctly, also by the distance at which the 
child can read the blackboard without straining his eyesight. Numer- 
ous studies have shown that the distance over which the ordinary 
teacher's voice will carry well is twenty-nine feet.* Allowing for a 
three-foot aisle at the end of the room, the standard length of the 
classroom has been placed at thirty-two feet. 

Width. — Here the points to be considered are whether or not the 
classroom is lighted from one side only and the provision of abundant 
light. In unilateral lighting, the width of any classroom should not 
be greater than twice the height of the top of the windows from the 
floor, provided the total glass surface is not less than one-sixth of the 
floor surface. The width of the room, therefore, will depend to a great 
extent upon its height. Windows should be so placed that they come 
within six inches of the ceiling and their lower edge should be four feet 
from the floor. They should generally be placed so that the light comes . 
on the left side of the child and the windows should be toward the back 
rather than toward the front of the classroom. Under such circum- 
stances the rays of light coming in the windows of this size and place- 
ment will carry into the room a distance equal to double the height 
from the top of the window to the floor. In considering the height 
of the ideal classroom, we will find that it is placed at twelve and a 
half feet. The height of the windows from the floor, therefore, will be 
twelve feet and the rays of light will carry twice that distance, or 
twenty-four feet, giving us the latter as the width of the classroom. 

Height. — It has been found that a classroom thirty-two feet long and 
twenty-four feet wide cannot have a ceiling higher than from twelve 
and a half to thirteen feet without seriously interfering with the type 
of heating and ventilation which is essential. Most mechanical 



EXAMINATION OF CHILDREN FOR PHYSICAL DEFECTS 717 

ventilating systems work best with a ceiling of such height and as any 
higher ceiling allows warm air to remain undisturbed just below the 
ceiling, that much space is wasted. The standard height, therefore, 
may be placed as twelve and a half feet. 

Lighting. — Mention has already been made of the size and location 
of the windows. The light should always fall from behind and always 
above the line of vision of the children. If the light is intense, dark 
green shades should be used. With east or west lighting, tan shades 
are sufficient. 

Walls. — The walls of a classroom should be painted a neutral color, 
preferably soft tan or green. A much darker shade of the same color 
should reach from the floor to a height of at least six feet. This will 
prevent undue reflection of light in the line of vision of the children. 

Blackboards. — Slate is generally considered the best material for 
blackboards as it does not glisten or reflect light. They may, however, 
be made of cement, paper or fiber. In the primary grades, the lower 
edge of the blackboard should be within two feet of the floor. In the 
elementary grades they should be from thirty to thirty-five inches 
from the floor. In order that there may be no eyestrain on the part 
of the children, the blackboards should be kept in a cleanly condition 
and washed at least once a day. Only white crayon should be used 
for the general routine of school work. Erasers should- be cleaned 
thoroughly each day, preferably with a vacuum cleaner. When this 
cannot be done, the erasers should be taken outdoors and thoroughly 
cleaned by being beaten or brushed with a large floor brush. 

School Books. — School books should never be printed on glazed 
paper. The length of the line should not exceed three and a half inches 
and the distance from line to line should never be less than one-eighth 
inch. No type smaller than long primer should be used for general 
reading. Small pica is preferable. For young children pica type 
should be used. In the kindergarten classes or the first grade, primer 
type is preferable. 

Desks and Chairs. — The most important factors in the correct 
'seating of children are (1) that the seats be of proper height and size 
for the pupils, (2) that the desks be placed at such a slant that the child 
will not strain either his body or his eyesight in assuming a correct 
position for easy desk work, and (3) that the chairs be so constructed 
that the backs afford natural support for the backs of the children in 
any position that may be required in the ordinary routine of class 
work. There are a large number of desks and chairs on the market 
which purpose to fulfil these requirements. They are of many types, 
some with both desk and chair movable, some with only the chair 
movable, some with desk and chair attached, and practically all at 
the present time adjustable to various sitting positions. Movable 
chairs have a possible advantage in open air classes in that they may 
be pushed aside and cots put in their places. They are objected to for 
regular classroom work, however, mainly because of fire hazards as it is 
felt that it is not possible to get children from school buildings as 
quickly with movable chairs as with those attached to the floor. 



71S CHILD HYGIENE 

When proper school furniture has been installed, it is essential to 
see that it is properly used. Desks and chairs should be adjusted each 
term to fit the pupils who are to occupy them. A practical rule for 
the height of the desk and chair consists in having the seat of the chair 
at such height that the child's feet rest evenly and firmly on the floor. 
Desks should extend two inches over the edge of the seat and be 
sufficiently high to allow the child's forearm to rest upon the lid 
without stooping of the shoulders. An easy way of computing these 
heights is to have the children, at the beginning of each term, stand 
with the back to the blackboard and have the teacher mark the exact 
height. The desks should then be adjusted so that the top is three- 
sevenths the height of the child, while the seat is two-sevenths of the 
child's height. Desks should preferably be individual and be placed 
so that there is an aisle space of at least two feet between the rows. 
The question of adjustable desk tops which may be slanted so that books 
may be held upon them for easy reading is one that applies to older 
children mainly. It has been mentioned by teachers that it is difficult 
to teach children to write on such a slanting surface but desks are now 
made so that their tops are adjustable and may be slanted for reading 
purposes and placed with only a slight degree of slant for writing, as 
required. Proper maintenance of seats and desks in the correct 
condition is of the greatest importance because of its bearing upon the 
acquisition of postural defects in children, particularly lateral curva- 
tures of the spine. Such defects are of common occurrence when 
children are seated at improperly adjusted desks. 

Ventilation. — During the past few years the question of ventilation 
of dwelling houses and school rooms has received an unusual amount 
of attention and many points in regard to it are still considered debat- 
able. The following factors, however, may be considered as having 
been determined : 

Air which is brought into buildings where persons live must be 
clean and of proper temperature, with the humidity in proper propor- 
tion to the temperature, and should be subject to a constant current 
of motion. Ordinary standards for classrooms have been placed at 
three hundred cubic feet of air space for each child. In England the 
required air space for each child is less than one hundred cubic feet. 
The standards of the Department of Education of New York City 
allow two hundred and fifty cubic feet. It may be assumed, however, 
that nothing less than three hundred cubic feet per child can be allowed 
if adequate standards of ventilation are to be maintained. Anything 
less does not permit of the required air changes without creating a 
serious draught. With three hundred cubic feet of air space for each 
child, and assuming that each child of elementary school age would 
require at least three thousand cubic feet of air per hour, it is seen that 
this would entail a complete change of air in the classroom once every 
six minutes. It is possible, however, to effect such change by the 
utilization of both natural and artificial methods of ventilation. In 
classrooms where there are few windows or where the latter open upon 



EXAMINATION OF CHILDREN FOR PHYSICAL DEFECTS 719 

a small or restricted court, it is probable that some type of mechanical 
ventilation will be essential. This is also true of wholly enclosed 
rooms, such as assembly rooms in the center of large schools. 

It is becoming more and more apparent that, except for these limi- 
tations, artificial systems of ventilation are not required in the modern 
school building and that natural ventilation by means of open windows, 
with proper window deflectors, may be accepted as the type of ventila- 
tion which is most conducive to the health of the pupils. 

It has been found that a temperature of sixty-eight degrees seems to 
be most conducive to proper classroom work in this country. The 
European standards are much lower, fifty degrees often being accepted 
as a proper temperature for classrooms in European countries. With a 
temperature of sixty-eight degrees Fahrenheit, a 40 per cent, humidity 
should be allowed in cold weather and 50 per cent, humidity in ordinary 
winter weather. 

Mechanical systems of ventilation depend upon the propulsion of 
air through ducts into the room and the extraction of the foul air 
through other ducts. Generally, the inlet ducts for fresh air are placed 
about eight feet above the floor and the outlet ducts are placed on the 
same side, with the openings near the floor. This fresh air, which is 
forced into the room, may be heated, washed, cleansed or filtered by 
means of special appliances before it reaches the classroom. 

The inadequacy of mechanical systems of ventilation has been 
shown by the difficulty of their proper maintenance. The care of such 
systems is usually placed with the janitor of the school and their effi- 
ciency depends in large degree upon his interest in this direction. 
Mechanical engineers claim that the installation and maintenance of 
such systems are problems attended with little difficulty but the practi- 
cal working out of such systems has not been wholly satisfactory. For 
this reason, as well as because it has been evident that the relation of 
ventilation to the health of school children is a subject of considerable 
importance, studies have been made from time to time with the object 
of determining the proper type of ventilation for classrooms. Taking 
the respiratory diseases as an index of the effect of ventilation upon the 
health of children, the Bureau of Child Hygiene of the Department of 
Health of New York City, in cooperation with the New York State 
Commission on Ventilation, conducted in 1915 and 1916 a study among 
5533 pupils in seventy-six classrooms in twelve schools in New York 
City. 

These classrooms were operated under three different types of 
ventilation: Type A was made up of classrooms ventilated by 
mechanical systems of ventilation and kept at a temperature of about 
68° F. In this type of classroom, the windows were kept closed. 
Type B classrooms were kept at a temperature of about 68° F. and 
ventilated wholly by open windows, no mechanical system being used. 
Type C classrooms were kept at or about 50° F., ventilation being 
wholly by open windows, no mechanical system being used. 



720 CHILD HYGIENE 

It was found in this study that : 

In the closed window, mechanically ventilated type of classroom, 
kept at a temperature of about 68° F., the rate of absence from respira- 
tory diseases was 32 per cent, higher than in the open window, naturally 
ventilated type of classroom kept at the same temperature and about 
40 per cent, higher than in the open window, naturally ventilated type 
of classroom kept at a temperature of about 50° F. 

In the closed window, mechanically ventilated type of classroom, 
kept at a temperature of about 68° F., the rate of respiratory disease 
occurring among pupils in attendance was 98 per cent, higher than in 
the open window, naturally ventilated type of classroom kept at the 
same temperature and about 70 per cent, higher than in the open 
window, naturallv ventilated type of classroom kept at a temperature 
of about 50° F. 

In this investigation it was also found that the relative humidity of 
classrooms, whether ventilated by natural or mechanical means, was 
not a causative factor in the occurrence of respiratory diseases among 
school children; and, further, that the occurrence of respiratory 
diseases among school children was not influenced by sex. 

The open window type of classroom mentioned in this investigation 
was the ordinary schoolroom with windows open from the bottom 
about six to eight inches. In some, window boards were used. In 
others, ordinary wood or glass window deflectors, placed at an angle 
from the window sill served the purpose. In this way no direct drafts 
were created. 

In all schools the classrooms should have the windows thrown wide 
open for a period of at least one hour each morning, lasting until 
within a half hour of the opening of school. At the end of each class 
period the windows should be opened for at least two minutes while 
the children are engaged in setting-up or running exercises. In country 
schools, where the heating of the schoolroom is a distinct problem and 
where ordinarily a stove is used for the purpose, the ventilation is apt 
to be a matter of great difficulty. Possibly the simplest method of 
ventilating a country schoolroom without draughts is to cut out the 
whole or part of the upper pane of glass of alternate windows and have 
the window frame covered with a layer of ordinary unbleached muslin. 
This may be tacked into place and changed and washed when it becomes 
soiled. The air filtering in through this cloth screen is not only cleansed 
but it does not create any strong current. It has the further advantage 
of subduing the light from the upper panes of the window. 

Cloakrooms. — It is the tendency in schools generally to place the 
cloakrooms in dark, un ventilated closets. The main features to be 
remembered are that the hygienic type of cloakroom must be well 
ventilated and that it must consist either of lockers or of hooks, so 
spaced that the clothes of one child will not come into contact with 
that of another. The individual locker system is undoubtedly the best 
but it is also expensive. Much the same result may be obtained by 
the use of the individual hooks properly spaced. For safety in case 



EXAMINATION OF CHILDREN FOR PHYSICAL DEFECTS 721 

of fire, it is better to have individual cloakrooms connected with each 
classroom. These cloakrooms or lockers may be so situated that an 
air exit may be placed in them and, with wire screens for doors, they 
may be sufficiently ventilated from the classroom. Care should be 
taken, however, to see that such lockers open either directly into the 
classroom or, if it is a separate closet, it must have a door of entry 
from the classroom and another which opens into the outside corridor, 
otherwise it may become a source of actual menace in case of fire. 

Toilets. — The toilet facilities in city schools are usually subject 
to the requirements of the local sanitary regulations. There should 
be provided, however, at least one toilet for every fifty children and 
an additional urinal for every fifty boys. Toilets for the sexes should 
be kept quite separate and distinct. The U-shaped toilet seat is 
advised, in order to prevent infection. In country schools the ordinary 
outhouse or privy must be placed in such a position that its drainage 
will not contaminate the water supply. Open privy vaults should not 
be allowed in any case. 

There are many types of privy vaults adaptable to country homes or 
schools which can be built at comparatively little expense. Details 
of such vaults may be obtained from the United States Public Health 
Service. In addition, there are on the market many types of chemical 
closets which have been found to be effective. These closets have the 
appearance of an indoor closet. They are connected with a drainage 
tank which receives the excreta, which is kept in a fluid state by means 
of the action of certain chemicals. At intervals these tanks have to be 
cleaned and the deposit taken away, but this is necessary only at 
infrequent intervals, and, in general, these closets are not offensive, 
are easily kept in order and entirely practical. 

Washing and Drinking Facilities. — The use of the common towel 
should be prohibited in all schools. When paper towels are not 
available, either because of the cost or the difficulty in obtaining them, 
each child should be advised to bring a clean towel from home each 
week, returning it to be laundered at the end of the week. Provision 
should be made in every school for adequate facilities so that the 
children may wash their hands after each visit to the toilet. Common 
drinking cups should not be allowed in any event, /but care must be 
taken in the installation of drinking fountains to see that only such 
types are employed where the child's mouth cannot rest upon the nozzle 
during the act of drinking. Generally speaking the types of drinking 
fountains which shoot a jet of water from a side opening or those where 
the convergence of several streams of water make a central fountain 
point are preferable. If cost is a consideration the ordinary faucets 
in any school building may be made into acceptable drinking fountains 
by having them turned upside down or extension pipes may be run 
from the faucets and regular nozzles attached. In country schools 
the question of drinking facilities is much more difficult to solve. 
Various types of easily made drinking facilities may be installed, as by 
placing a hogshead on a high level and having pipes reach down, 
46 



722 CHILD HYGIENE 

ending in a U-shaped nozzle at the end. This, with a convenient 
stopcock to regulate the flow of water, can be made an acceptable 
drinking fountain, as far as the mechanical side of the matter is con- 
cerned. The difficulty lies in keeping the tank clean. For that 
reason individual paper cups should be advised, to be used with the 
ordinary water supply. 

Maintenance of School Buildings. — All classrooms and hallways should 
be cleaned thoroughly each day. Dry sweeping and dusting should 
not be allowed. Various types of oil dressings, which are thrown into 
the room in the form of a spray, which settles on the floor and desks, 
may be recommended. After use of these dressings, it is simply 
necessary to wipe up the floors with a soft cloth, and mopping or sweep- 
ing is not essential. Vacuum cleaners should be used, of course, 
whenever possible. Walls and desks should be wiped off with a damp 
cloth at least once a week. In the case of infectious diseases occurring 
in any classroom, the use of disinfectants and various methods of 
fumigation are not advised. Windows of such classrooms should be 
kept open for at least twelve hours and the walls, furniture and floors 
thoroughly scrubbed with soap and water. 

Special Classes. — In recognition of various types of physical infirm- 
ities or defects, practically all city schools have now segregated 
certain types of children into special classes. Thus w T e have open-air 
classes for anemic and tuberculous children, classes for crippled 
children, classes for sight conservation, classes for the blind and classes 
for children with cardiac disease. The main features of these classes 
are that they should be easily accessible, particularly in the case of 
the cardiac classes, and care should be taken to see that these children 
do not have to climb stairs. In classes for crippled children, a special 
type of desk and chair is necessary. In open-air classes a standard 
equipment may be used. Here it is advised that the parka, thick 
bloomers or trousers and boots, mittens and hood be "used generally, 
instead of the sleeping bag, on account of the greater use of movement. 
In all of these classes fresh air is a matter of the first importance and 
adequate ventilation or outdoor life should be maintained at all times. 
Food is important, also, and there should be provided a lunch of milk 
or cocoa and bread and butter at eleven o'clock, a hot lunch at twelve- 
thirty including soup and cocoa, with sandwich and hot meat and 
vegetables, and another meal at four o'clock, consisting of milk or cocoa 
and crackers or bread and butter. Special methods of training these 
children need not be considered as relating to their health except that 
such children should be under close supervision, with particular 
reference to the care of their particular defect or abnormality. For 
this purpose, it is usually better, as an administrative measure, to 
assign certain doctors and nurses to the exclusive control of these 
special classes. It has been found that greater interest is aroused 
and more effective work accomplished when this is done. 



CHAPTER XXVI. 

SOCIOLOGIC AND ECONOMIC ASPECTS OF DISEASE. 

By CHARLES F. BOLDUAN, M.D. 

The student of medical history cannot fail to be impressed by the 
fact that until recently the practice of medicine has been confined to 
the art of healing the sick. It has dealt almost entirely with the indi- 
vidual and has considered disease purely from an individualistic stand- 
point. A different viewpoint was gradually introduced, the result of 
the development of what was called "public medicine," in Italy during 
the Renaissance. This taught the value of quarantine, isolation and 
other preventive measures, and gradually led to the establishment of 
our present systems of public health administration. In the latter 
half of the nineteenth century important developments in the natural 
sciences, and especially the epoch-making discoveries of Pasteur, 
Koch and their contemporaries, led to a reconsideration and recon- 
struction of the current views regarding the nature and cause of 
disease and to the adoption of concepts based largely on laboratory 
investigations. It would be foolish to deny the debt which medical 
science owes to introduction of these laboratory concepts. Neverthe- 
less, we should not fail to recognize the fact that a too constant reliance 
on laboratory methods alone has proved distinctly detrimental and 
that it is time to adopt a broader viewpoint in order to promote 
public health. 

Under the spell of the wonderful discoveries in bacteriology of the 
eighties and nineties of the last century there crept into the writings 
of most medical authors statements concerning the etiology of the 
infectious diseases, which in the light of our present knowledge must 
now be considered as entirely inadequate. Almost without exception 
these writers speak of the tubercle bacillus as being the cause of tuber- 
culosis; the pneumococcus as the cause of pneumonia; the staphy- 
lococcus as the cause of boils, furuncles and abscesses; the gonococcus 
as the cause of gonorrhea, etc. Only in recent years do we hear a 
protest raised at this unwarranted use of the expression "the cause." 
In an interesting essay published several years ago von Hansemann 
points out that it is extremely rare to have relations so simple that any 
one particular microorganism can be regarded as the cause of some one 
disease. Almost invariably it is but one of the causes, an essential one 
to be sure, nevertheless only one of several. For the student of public 
health this distinction is of the greatest importance, and it may be well, 
therefore, to give the matter further consideration. 



724 SOCIOLOGIC AND ECONOMIC ASPECTS OF DISEASE 

Let us take, for example, pulmonary tuberculosis. Practically all the 
text-books speak of this as caused by the tubercle bacillus, and that 
this is one of the essential causes is acknowledged. Nevertheless, we 
know, from autopsy studies, that practically all adult human bodies 
show evidences of tuberculosis infection. Moreover, we are all fre- 
quently exposed to the inhalation of tubercle bacilli, yet only a rela- 
tively small proportion of us develop pulmonary tuberculosis, j Evi- 
dently, then, the presence of the tubercle bacillus is not synonymous 
with tuberculosis. To say that the body resistance constitutes the 
other necessary factor is to be satisfied with a mere label, whose accept- 
ance as an explanation shuts off further inquiry into the unknown. 

Inasmuch as many of our public health problems have failed of 
solution when attacked from the standpoint of the germ as the cause, 
e. g., pneumonia, is it not worth trying to discover all the causative 
factors in any given disease, to ascertain which of these are essential 
factors, and, this much determined, how any one essential factor may 
be successfully attacked so that the occurrence of the disease may be 
prevented. 

Among the causative factors which almost all writers either pass 
over very lightly or ignore altogether there are none of greater impor- 
tance to the health official than those dealing with the social and 
economical conditions pertaining to the disease. This point is clearly 
presented by Grotjahn, who speaks of a "social pathology" of disease. 
In recent years this aspect of disease is beginning to receive some 
consideration. Thus in the oft quoted report of the United States 
Children's Bureau regarding infant mortality in Johnstown, Pa., we 
find tables showing that the infant mortality-rate varies with the family 
income — the lower the income the higher the infant death-rate. In 
the case of tuberculosis it has often been pointed out that the frequency 
of the disease increases directly with the number of persons per room. 

The high infant death-rate among illegitimate children has long been 
known. The high prevalence of venereal disease in seaport towns is 
also recognized. 

It may be helpful to classify the ways in which social and economical 
conditions are causally related to disease. Following is the classifica- 
tion suggested by Grotjahn: 

1 . The social and economic conditions create or favor the disposition 
to the disease. 

2. The social and economic conditions bring with them the condi- 
tions which are necessary for the disease to develop. 

3. The social and economic conditions constitute the means of trans- 
mission of the disease. 

4. The social and economic conditions influence the course of the 
disease. 

Of perhaps equal importance to the health officer, and certainly to 
the community, is the influence exerted on the community's social and 
economical structure by disease. It is clear that from this standpoint 
the significance of disease depends primarily on its prevalence. No 



TUBERCULOSIS 725 

matter how dangerous to the individual a given disease may be its 
significance to the community is slight if it is infrequently met with. 
More than this, however, we must take into consideration the character 
of the disease, i. e., to learn in what form the disease most frequently 
appears. The classic text-book type of the disease is not always the 
predominant type. 

Besides the actual prevalence of a disease, society is much concerned 
as to the age of the persons chiefly attacked. Assuming three diseases 
equally prevalent, one affecting chiefly infants, another chiefly young 
and middle-aged adults, and the last, chiefly those in advanced life, 
one would have no question as to which was most important from the 
social standpoint. 

From the social standpoint the outcome of a disease is of great 
importance to the community. The various outcomes may be enumer- 
ated as follows: death, complete recovery, physically handicapped, 
chronic invalidism, predisposition to other diseases, transmissible 
impairment. 

When one considers the many complex interrelations between disease 
on the one hand and social and economic conditions on the other, is 
it not likely that a more careful study of these relations — in other 
words, of the social pathology of disease — will help us reduce the 
prevalence of many diseases which up till now have baffled all our 
efforts? Has our failure perhaps been due in some instances to a too 
restricted point of view, and have we been treating symptoms rather 
than causes? In this connection one may call attention to the state- 
ment made by Gorgas in commenting on the influence of overcrowding 
on the spread of disease in the Panama Canal Zone. Gorgas gave it 
as his opinion that the introduction of the single tax, by promoting a 
greater use of land for building purposes, would constitute a public 
health benefit of incalculable value. This is an illustration of how 
fundamental a viewpoint of health problems is taken by a successful 
health administrator. 

In order to give the reader some idea of the nature of the studies 
made in the field of social pathology, and especially to serve as a typical 
picture of the newer viewpoints thus revealed, I have collected in the 
following pages some of the more important social data relating to 
tuberculosis and to infant mortality. Much of the material is taken 
from GrotjahnV excellent work on Social Pathology, to which the 
student is referred for further details. 

TUBERCULOSIS. 

Tuberculosis is well termed a disease of the masses. The fact already 
alluded to that most human adults are found at autopsy to show 
evidences of tuberculous infection indicates that something more than 
the mere presence of the tubercle bacillus is involved as a causative 

1 Soziale Pathologie, 2d edition, August Hirschwald, Berlin, 1915. 






726 SOCIO LOG TC AXD ECONOMIC ASPECTS OF DISEASE 

factor. Inasmuch as the importance of a disease, from the community's 
standpoint, is often directly proportional to its frequency, it may be 
pointed out that in many communities tuberculosis is responsible for 
more deaths than any other individual cause of death. Moreover, it 
affects persons in the best period of life, young and middle-aged adults. 
This is well shown by the following typical table giving the age distri- 
bution of deaths from tuberculosis. The conditions here shown for 
New York City are practically the same everywhere: 

DEATHS FROM PULMONARY TUBERCULOSIS, NEW YORK CITY, 1916. 





Male. 


Female. 


Under 15 years 


... 36 


50 per 100,000 


15 to 24 " 


... 121 


118 


25 to 44 " 


... 289 


158 


45 years and over 


. . . 411 


124 " 



It is also to be noted that males are more frequently affected than 
females, a fact which has generally been explained by the larger pro- 
portion of males in industrial life. In recent years the proportion of 
deaths of females from tuberculosis is said to be rising in some of the 
English and German industrial centers, due to the increasing proportion 
of women entering industrial life. 

It has long been recognized that the incidence of tuberculosis is 
closely related to the prevailing occupations. It is high among cutlery- 
grinders, marble- and stone-cutters, cigar- and tobacco-workers, com- 
positors, printers and pressmen and hat- and cap-makers.. On the other 
hand the prevalence of tuberculosis is low among engineers and sur- 
veyors, teachers, lawyers, soldiers and sailors, steam-railway employees, 
farmers, planters and coal-miners. 

Dusty trades are closely related to the prevalence of tuberculosis, 
but the character of the dust appears to play a highly important 
role. Among stone-workers it is a matter of common observation that 
limestone dust is but little harmful; flint and quartz dusts, on the 
other hand, are exceedingly dangerous. Coal dust appears to be quite 
harmless, so far as tuberculosis is concerned, for coal-miners have a 
low tuberculosis rate. Millers formerly had high tuberculosis rates, 
apparently due to stone dust from the mill-stones. Since the intro- 
duction of modern steel-roller mills the tuberculosis rate is said to have 
markedly decreased. 

Writers on tuberculosis make frequent reference to the relation 
between tuberculosis prevalence and housing conditions. They point 
to the frequency with which the consumptives are found living in 
.poorly ventilated, dark, mean tenement houses, and this cannot be 
disputed. It must not be forgotten, however, that this in itself does 
not prove causal relationship, or, even admitting such relationship, 
in what proportion of cases the disease is the cause and in what effect. 
It is well known that tuberculosis makes such a drain on the family 
income that these families are found moving from one house to another, 
and almost always to cheaper and poorer quarters. However, there 



TUBERCULOSIS 727 

can he no question that improved housing constitutes one of the 
pressing needs in the campaign against tuberculosis. 

The number of rooms occupied by the consumptive and his family 
is important, for unless a separate sleeping room can be provided for 
the patient the spread of infection cannot be avoided. 

It must not be supposed that wretched housing conditions, together 
with high tuberculosis rates, are found only in city slums. The filthy, 
overcrowded farmhouse is not at all uncommon, and undoubtedly 
plays an important part in the dissemination of tuberculosis among 
the rural population. 

Tuberculosis is very directly related to economic conditions. Its 
prevalence decreases as the economic conditions improve. This is 
well shown by the following compilation concerning tuberculosis in 
Hamburg, 1901-1905. This shows the deaths from tuberculosis per 
100,000 population, in five different groups arranged according to 
taxable • income : 

Death-rate, 

Number of tuberculosis, 

A taxable income of persons. per 100,000. 

900 to 1200 marks 71,526 482 

" 2000 " 48,855 447 

" 3500 " 21,397 274 

" 5000 " 8,342 252 

over 5000 " 14,323 120 

From the social standpoint an important consideration is the fact 
that not only does tuberculosis cause a very large proportion of deaths 
but also causes a large amount of physical impairment and invalidism. 
What this amounts to in years may be gauged from the following table 
compiled by Koelsch from German sickness insurance statistics. In a 
certain nine-year period 161,409 men under sixty years of age were 
granted pensions by sick benefit funds. With the aid of a life table to 
show what the normal expectancy of life was at the different age 
periods, it was found that this precocious invalidism had caused a 
loss of 1,842,413 years, an average of 11.4 years for each pensioner. 
The form of the calculation was as follows: 

38 pensioners were only 20 years old. Loss amounted to 1,280 working years. 
1097 " " 21 " " " 36,062 

1910 " " 30 " " " 48,602 

Inasmuch as tuberculosis was the cause of invalidism in 13.3 per cent, 
of all the cases the author concludes that tuberculosis in these nine 
years caused a loss of 239,210 working years. 

In dealing with the care of tuberculosis patients the sociopatholog- 
ical viewpoint insists that the various measures taken by the com- 
munity be economically sound. Thus in caring for advanced indigent 
cases of the disease the provision of expensive public hospitals, where 
the life of the patients may be prolonged as far as possible is generally 
condemned as being economically unsound. Unless such a patient 
can be kept in a condition where he will be at least self-supporting 
it is a mistake to seek to prolong his life. He should, of course, be 



728 SOCIOLOGIC AXD ECONOMIC ASPECTS OE DISEASE 

made physically comfortable, but aside from this, so far as the com- 
munity is concerned, the earlier the fatal ending the better. 

Entirely in harmony with these principles is the attempt in various 
quarters to provide suitable remunerative occupations for patients 
discharged from tuberculosis sanatoria. The excellent work done in 
New York by the Committee on the Care of the Jewish Tuberculous 
and in Edinburgh by Sir R. W. Philip shows what can be done in this 
direction. 

INFANT MORTALITY. 

The number of infants born who fail to survive the first year of life 
is still very great. In the United States, in 1918, from about 80 to 
150 infants out of every thousand infants born alive died during their 
first year. In some parts of Russia one out of every three infants born 
succumbs during the first year. In New Zealand, on the other hand, 
the rate averages about 50 per 1000. In Calcutta, in 1915, several 
parts of the city had rates approaching 500 per 1000 births. 

Examining into the causes of high infant mortality, one is impressed 
at once by the remarkable difference between the mortality of breast- 
fed infants and those brought up on the bottle. This is well illustrated 
by the following table: 

INFANT MORTALITY — ACCORDING TO TYPE OF FEEDING. 







Breast-fed exclusively. 


Mixed food, breast and 
other. 


Artificial food, no breast 
milk. 






Deaths in first 




Deaths in first 




Deaths in first 




Babies 
alive 

at indi- 
cated 
age. 


Total. 


year. 


Total. 


year. 


Total. 


year. 


Age of baby. 


No. 


Rate 
per 
1000 
alive 
at 


No. 


Rate 
per 
1000 
alive 

at 


No. 


Rate 
per 
1000 
alive 

at 










speci- 
fied 






speci- 
fied 






speci- 
fied 










age. 






age. 






age. 


End of 3 mos. 


1355 


987 


46 


46.6 


175 


10 


57.1 


193 


32 


165.8 


End of 6 mos. 


1313 


616 


18 


29.2 


447 


10 


22.4 


250 


18 


72.0 


End of 9 mos. 


1282 


220 


3 


13.6 


709 


8 


11.3 


353 


4 


11.3 



The question at once arises, are the mothers physiologically unfitted 
to nurse their infants in so large a proportion of cases, or are there 
other reasons why they do not do so? In answer to this we may cite 
the figures compiled by Schwarz, director of the pediatric department 
of Dr. Hill's maternity clinic in New York. Schwarz found that of 
1500 mothers only four were physiologically unfitted to nurse their 
babies. All the rest could do so when encouraged by proper care at 
and after confinement. Of these 1500 mothers, 96.9 per cent, nursed 
one month, 89.1 per cent, three months and 77 per cent, six months. 



IXFAXT MORTALITY 



729 



Why, then, do not more mothers nurse their babies? A partial 
answer is supplied by the following table from Johnstown, Pa.: 



Infants breast fed. 



Wholly 



Partiallv 



Together. 



Infants only 
artifieiallv fed. 



Infants - cent. Infan ^ <£S. InfantS cent. Infant5 " Si 



Mother gainfully 
employed, 678 



155 22.86 94 13.86 249 36.73 42! 



63.21 



Mother not gainfully 

employed, 5915 " 3046 51.50 845 14.29 3891 65.78 2024 34.22 



This table also furnishes us with an explanation of the fact that 
infant mortality-rates are usually high in industrial centers employing 
large numbers of women. Moreover, the steady rise in the proportion 
of women engaged in industrial pursuits makes it extremely important 
to take cognizance of the relations here pointed out. 

It has long been recognized that the infant mortality-rate is closely 
related to hot weather. This is well shown by the following tables 
one from the U. S. Registration Area and the other from Germany. 
It will be noticed that in both the infant mortality-rate rises markedly 
during the months of July, August and September : 

Deaths. Deaths. 

Diarrhea and enteritis under 2, All causes, under 1, 

U. S. Registration Area, German cities, 

Months. 1918. 1911. 

January 1775 24,384 

February 1712 23,407 

March 2040 24,459 

April 2192 23,291 

May 2712 22.709 

June 4027 23.159 

July 6811 38,110 

August 9822 67,339 

September 8128 46,133 

October 4458 26,041 

November 2394 19,716 

December 1682 20.714 



If the cause of this summer's increase is investigated, it is found to 
be due largely to a marked increase in the proportion of deaths from 
diarrheal disease. These, in turn, are found to be very much more 
frequent among bottle-fed infants than among the breast-fed. At one 
time it was thought that the chief factor in the association of diarrheal 
disease with bottle-feeding lay in the improper modification of cow's 
milk, and much emphasis was therefore laid on methods designed to 
make cow's milk similar to human milk. 

Thanks to the fundamental investigations, both laboratorv and elin- 



730 sociolocic ANb economic aspects of disease 

ical, conducted by Park and Holt the attention of physicians and 
health officers was directed to the quality of the milk supply, and 
particularly to the bacterial content of the milk, as being directly 
responsible for the high death-rate from diarrheal disease, especially 
in the summer months. It is almost impossible to overestimate the 
beneficial influence of these investigations. Through the resulting 
improvement of the milk supply they have caused the saving of thou- 
sands of lives annually. 

The investigations showed especially the very great importance of 
keeping milk cold so as to retard the multiplication of bacteria. They 
thus gave renewed impetus to the movement for supplying the poor 
with ice during the hot weather. In New York City this movement 
has undoubtedly played an important part in reducing the infant 
mortality during the summer months. This, then, brings out another 
close connection between infant mortality and economic conditions, 
for it is clear that where such ice charities do not exist, many poor 
people must go without ice during the hot weather. 

From a sociological standpoint it is important to recognize the justice 
of the demands now made by a community to have a clean and safe 
milk supply. Experience has shown that this can be assured only if 
strict supervision and control is exercised by municipal or State health 
authorities. But the community has a right to demand even more, 
and that is to have such a milk supply made available at a price within 
reach of the masses. Because of its unique character as an almost 
indispensable food for children there is a growing disposition to regard 
the milk supply in the same light as the water supply and to argue 
for a milk supply controlled and perhaps distributed by the community. 
In this connection attention may be called to the statements by the 
New York City health authorities that the increase in the price of milk 
in 1917 was accompanied by an increase in the deaths of infants from 
diarrheal disease. In Europe the present marked curtailment of the 
milk supply is said to have resulted in a large increase in infant mor- 
tality. 

From the sociological standpoint it is particularly interesting to note 
there is almost always some degree of parallelism between the infant 
mortality-rate and the birth-rate. In fact, authorities consider that 
the decrease in the infant mortality-rate, so widely observed, is due 
more to the decline in the birth-rate than to any other factor. Flugger 
expresses himself as follows: "When many children are born the nurs- 
ing care given the later born is less careful, the family income proves 
insufficient and the mothers are not able or not willing to nurse the 
later born at the breast; when fewer children are born these con- 
siderations disappear to a greater or less degree and a larger proportion 
of the children remain alive." 

This is w T ell borne out by the two following tables, one from Saxony, 
in 1885, and the other from the Johnstown survey, 1911. In both 
tables the infant mortality-rate is shown according to the order in which 
the child was born. Although the rates in the two tables naturally 



infantImortality 731 

differ widely the agreeement between the course of the mortality curve 
is striking: 

Saxony, 1885. Johnstown, Pa., 1911. 

Infant mortality-rate. Infant mortality-rate. 

First child 229 First child 143.6 

Second child 204 Second child 131.2 

Third child 212 Third child 144.2 

Fourth child 232 Fourth child 142.0 

Fifth child 263 Fifth child 178.1 

Sixth child 289 Sixth child 175.5 

Seventh child 311 Seventh child 192.1 

Eighth child 332 Eighth child 165.4 

Ninth child 361 Ninth child 128.2 

Tenth child 413 Tenth and later . . . . 252.3 

Eleventh child 514 

Twelfth and later .... 597 

The age of the mother also plays a part in the infant mortality-rate 
Following is a table reproduced from the Johnstown survey: 

Infant 
All mothers. mortality-rate, 134. 

Mother under 20 years 136 

20 to 24 " 121 

25 to 29 " 143 

30 to 39 " 135 

" 40 and over 148 

Considerable influence is exerted by the character of the attendance 
at birth, but in studying statistics bearing on this point it must be 
remembered that difficult cases of labor are more commonly in the 
practice of physician. Following are two tables bearing on this: 

Johnstown Survey, 1911. Newark, N. J., 1916. 

All births (infant death-rate) . 134 All births (infant death-rate) 87.6 

Midwife in attendance . . 179 Midwives in attendance . . 70.7 
Physician in attendance . . 100 Physicians in attendance . . 74.3 

In hospitals 97.4 

It must also be remembered that certain of the European nationalities 
are more likely to have a midwife in attendance than are Americans 
or Irish- Americans. It follows, therefore, that the problem is compli- 
cated by the introduction of the nativity-of-mother factor. How great 
a part this plays may be gauged from the study made of New York 
City's statistics by Guilfoy. They relate to the year 1915. Guilfoy 
found that the infants of parents of Russia-Poland and of Austro- 
Hungarian birth had an extremely low death-rate (80 per 1000). 
Infants of Italian mothers had a death-rate of 103; those of native 
mothers a rate of 106; those of German mothers, 115; those of Irish 
mothers, 119. 

In the United States an important factor influencing the infant 
mortality-rate of any community is the size of the negro population. 
In New York in 1915 while the infant mortality-rate as a whole was 
98.2, that of negro infants was 202, while that of white infants was only 



732 SOCIOLOCIC AXD ECONOMIC ASPECTS OF DISEASE 

96.2. Tn one section of the city, the densely populated negro quarter 
known as Columbus Hill, the infant mortality-rate was 314 per 1000 
births. 

It must not be supposed, however, that the high infant death-rate 
among negro infants is necessarily due to some constitutional inferi- 
ority of the negro stock. Among the causes for the high rate among 
negroes, Sobel, who has given this problem special study, enumerates : 
" illegitimacy, syphilis, tuberculosis, alcoholism, overcrowding, lack of 
industrial opportunities for men, gainful employment of mothers, low 
average wages, entrusted care of infants to mammies and irresponsible 
neighbors, ignorance, superstition, extensive employment of quack 
remedies and patent medicines." 

It should also be noted that the infant mortality-rate is invariably 
higher among illegitimate children than among legitimate. This is 
well shown by the following table reproduced from Prinzing, the 
figures representing the infant death-rate per 1000 births. 

1901-1905. Legitimate. Illegitimate. 

Prussia 179 331 

Bavaria .229 321 

Saxony 233 329 

Wurttemberg .210 289 

Baden 155 298 

Germany 188 320 

Austria 207 277 

France 129 240 

The Netherlands 134 223 

Finland 135 190 

Italy 164 232 

Although the figures are small the results of the Johnstown survey 
w T ere practically identical with those shown in the above table. Thus 
out of 34 illegitimate infants 9 died in the first year — 281; out of 1517 
legitimate infants, 187 died in the first year — 130 per 1000. 

The reasons for this high death-rate among illegitimate infants are 
not far to seek. Many of the infants are abandoned by their mothers 
and are picked up as foundlings, sometimes after severe exposure; 
many of the infants are the victims of baby farming; they are liable 
not to have maternal care, for the mother has no incentive to keep the 
infant alive; artificial feeding is especially common, for the mother is 
usually compelled to go back to some gainful occupation. 

The value of prenatal care of mothers is just beginning to be appre- 
ciated by health officers. In New York City the infant mortality- 
rate among mothers supervised by the Bureau of Child Hygiene for 
some time prior to the birth of the infant is considerably lower than in 
those not so supervised. How proper prenatal care of the mother 
directly affects the offspring is well shown in the following table com- 
piled by Merletto-Ferrara, w r hich shows the weight of the newborn 
infant as affected by the number of days prior to the confinement 
that the mother could give up active work: 



INFANT MORTALITY 733 

Body weight of mother. 
Days at rest immediately 50 to 60 kg. 60 to 70 kg. 

preceding confinement. Weight of infant, g. 

days 2752 2903 

10 " 2824 3014 

20 " 3012 3174 

30 " 3034 3223 

40 " 3212 3326 

One often reads of high death-rates being ascribed by health officers 
and others to ignorance on the part of the public. In this connection 
it may be well to call attention to the interesting findings of the 
Johnstown survey Inquiries made as to the literacy of the mother 
showed the following: 

Among literate mothers — 445 births, 62 infant deaths, an infant 
mortality-rate of 148. Among illiterate mothers — 246 births, 49 infant 
deaths, an infant mortality-rate of 214. 

To a large extent many of the foregoing social and economical 
relations are themselves dependent on one fundamental economical 
factor, namely, family income. How great a difference in infant 
mortality is exerted by this factor is well shown by the following, 
giving the infant mortality-rate in Berlin in 1904: 

Infant mortality in the well-to-do sections (Friedrichstadt and 

Tiergarten) 52.0 

Infant mortality in the poorer sections (Wedding) 420 . 

Infant mortality in the city as a whole 196.0 

The special value of the Johnstown survey (1911) lay in the emphasis 
placed on the relation between family income and infant mortality. 
The following instructive table is included in the report: 

Infant 
Father's income. mortality-rate. 

Under $521 annually 197.3 

$521 to $624 " 193.0 

$625 to $779 " 163.0 

$780 to $899 " 168.0 

$900 to $1199 " 142.0 

$1200 and over . . . . 102.0 

A similar result is shown in the survey conducted by the Children's 
Bureau, Manchester, N. H., in the fall of 1914. The figures show the 
infant death-rate per 1000 reported births: 

INFANT MORTALITY-KATE AS RELATED TO FATHER^ EARNINGS, 

MANCHESTER, N. H., 1914. 

Infant 
Father's income. mortality- rate. 

Under $494 ...:. 262.4 

$494 to $571 145.7 

$572 to $675 . 191.7 

$676 to $883 145.7 

$884 to $1091 146.2 

$1092 and over 53.2 

It is obvious that the size of the family income will also determine 
the character of the family's environment, thus: general character of 



734 SOCIOLOGIC AND ECONOMIC ASPECTS OF DISEASE 

the neighborhood, type and condition of house, number of rooms, 
character of the water supply, whether sewer connection is present, 
whether outdoor privy is present, whether there is a bath-room, etc. 

From what has here been presented it is clear there is no exaggeration 
in saying that in no other domain of public medicine can more intimate 
relations be discovered between mortality on the one hand and social 
and economical conditions on the other than exist among the causative 
factors of infant mortality. Only by giving the various factors due 
consideration can we hope to reduce infant mortality to its lowest 
possible level. In this connection the reader is urged to study Special 
Report Series Xo. 10, issued by the Medical Research Committee, 
London, and bearing the title "The Mortalities of Birth, Infancy and 
Childhood" His Majesty's Stationery Office, 1917. 



MALARIA. 

In malaria, as it is observed in our Southern States, we are probably 
dealing with a disease carried by negro slaves from Africa and con- 
stituting one of the disastrous and unexpected consequences of the 
demand for cheap labor. This disease, morevoer is one to which, the 
negro, through countless generations of contact with the infection, 
has acquired a fair degree of tolerance, so that he is able to with- 
stand malarial infection much better than his white neighbor in the 
South. The result is that w T here malaria has become very prevalent 
the physically more resistant but economically less efficient negro 
has replaced the more susceptible, more efficient white inhabitant. 
In consequence of this large areas of fertile land, highly suitable for 
productive agriculture, lie almost untilled. In these sections the 
railroads pass through great stretches of country, taking on and dis- 
charging almost no freight. According to a recent survey made in 
several counties in Georgia, malaria cost the affected communities 
not less than $14 per acre of tilled land, surely an enormous economic 
burden. 

But a remarkable change is taking place, so that at present one may 
find numerous communities waging an energetic campaign against 
malaria. While Federal, State and local authorities are cooperating, 
it must be noted that usually more than half of the expense of these 
operations is being borne by the local communities. Why this rather 
sudden awakening? There have been no recent great discoveries 
regarding antimalaria methods, and it cannot all be due to the inten- 
sive educational propaganda which the United States Public Health 
Service has carried on throughout this region nor to the stimulus 
afforded by the "extra cantonment" health work carried on during 
the war. The answer is found in the material prosperity due to the 
high price of cotton prevailing during the past few years, and so we 
have another striking example of the topic discussed in this chapter. 






OTHER DISEASES 735 



OTHER DISEASES. 

The data given under tuberculosis, infant mortality and malaria 
will give the student some idea as to the role played by social and 
economic factors in disease. The examples could easily be multiplied 
and extended. Thus by consulting the chapter on Industrial Hygiene 
the reader may note the important part played by" occupation in the 
etiology of disease. 

In pellagra recent investigations have shown a marked relation 
between the development of this disease and a monotonous, unbal- 
anced diet. Similar conditions are observed in beri-beri in the orient. 
During the recent war a number of observers called attention to various 
pathological conditions apparently associated with dietary deficiencies, 
among them war edema, xerophthalmia, war amenorrhea, scurvy 
and pellagra. In most of these conditions the deficiency was appar- 
ently largely in the accessory food substances, the so-called "vita- 
mines." When one considers how easily food supply may be dis- 
turbed (war, financial crises, failure of crops, failure of transportation, 
floods and the like) the influence of social and economic factors on 
diseases of nutrition will readily be understood. 

In typhus we are dealing with a disease associated largely with 
filth, poverty and ignorance. It is significant that with this disease 
unduly prevalent in Europe at the present time, little apprehension 
is felt in the United States, owing to our confidence in the high stand- 
ards of cleanliness and sanitation which prevail in this country. 



CHAPTER XXVII. 

PUBLIC HEALTH EDUCATION. 

By CHARLES F. BOLDUAN, M. D. 

Historical. — Although health education definitely organized as 
such, as the work of health administrators, is of recent development, 
instruction in health matters in the form of laws and regulations dates 
from the remotest times. One of the earliest codes of health regulations 
with which we are familiar, namely the Mosaic, is remarkable for the 
fact that many of the regulations are in entire harmony with the 
recognized principles of hygiene of the present day. This is especially 
true of the warnings against discharges and eruptions from the body, 
of the emphasis placed on washing and bathing as a means of puri- 
fication, and of the explicit directions for proper disposal of excreta. 1 

In ancient Greece and Rome the magnificient public baths (thermal), 
the remarkable systems of public water supply including masonry 
aqueducts which constitute monuments to ancient engineering skill, 
the enormous sewers (cloacae), all testify to an appreciation of sanitary 
requirements. Like so much in other departments of human progress 
this appreciation appears to have dwindled, almost to the point of 
disappearance, during the centuries which followed. 

With the low standards of medical knowledge prevailing during the 
dark ages, it is not surprising to find practically no traces whatsoever 
of activities relating to public health education. After the Renaissance, 
however, and apparently mainly because Europe was repeatedly 
devastated by various plagues in the 13th, 14th and 15th centuries, 
the need appears to have been felt for furnishing authoritive informa- 
tion regarding the dreaded plagues. The result was the publication 
of numerous leaflets usually spoken of by scholars as " plague tractates." 
An interesting collection of these by Sudhoff indicates a wide range of 
titles, including leprosy, syphilis, plague, alcoholism, and sweating 
sickness. These tractates thus constitute the forerunner of the health 
leaflets published by present-day health authorities. Interest in 
matters of health and sanitation appears to have subsided, however, 
for it is certain that even so recently as two hundred years ago condi- 
tions throughout the world were most unsanitary. 

A reawakening of interest in public health is observed, mainly in 
England, in the early part of the nineteenth century, and we find, 
as a result, that communities concern themselves more actively in the 
provision of pure water supplies, in the disposal of refuse, the con- 

1 See Especially Leviticus XV, and Deuteronomy XXIII. 



PUBLIC HEALTH EDUCATION 737 

struction of better streets, etc., in other words, in matters of municipal 
sanitation. Let it be noted that these are provided for the individual 
by municipal authorities. 

Toward the end of the century, especially during the eighties, a 
remarkable change may be observed. The important bacteriological 
discoveries initiated by Pasteur and Koch, establishing, as they did, 
the infectious nature of many common diseases, placed a much more 
personal obligation on the individual members of the community to 
safeguard the public health than had hitherto existed. In order, how- 
ever, to derive substantial aid from the individual it was first necessary 
to make him recognize the obligation and to instruct him how to 
cooperate with the authorities. Accordingly, we find health depart- 
ments undertaking the publication of simple leaflets dealing with the 
more important communicable diseases. Almost invariably these con- 
tain instructions for dealing with a case of some particular infection, 
and they are distributed, as a rule, only to the families in which such a 
disease exists. While the fact is recognized that most infections are 
much more readily prevented than cured, very little is done by the 
health authorities beyond dealing with the cases of the disease as they 
occur. For example, in the domain of infant mortality, in which so 
much progress has been achieved in the past ten or fifteen years, a 
large amount of effort was expended in hunting out and providing 
medical care for sick babies in summer time. That this was absolutely 
illogical and ineffective in combating infant mortality was not then 
recognized. 1 

Tracing the further development of health education, attention must 
be called to the campaign begun in the late eighties for the suppression 
of tuberculosis. Developed more effectively in the United States than 
anywhere else in the world, this campaign has exerted a profound influ- 
ence on the methods of public health work generally and on health 
education in particular. Among the former may be mentioned the 
introduction of the municipal diagnostic laboratory and of home visi- 
tation by public health nurses, the impetus given to the housing move- 
ment, etc. Among the latter are the introduction of health exhibits, 
health lectures, health days or weeks, health primers, health posters, 
health " movies," etc. Of paramount importance was the fact that the 
educational campaign was preeminently one of prevention and that 
it was carried on among all the people, and not, as had so generally 
been the case before, only among those already ill. 

In view of the success attending the campaign against tuberculosis, 
it was natural to utilize very similar methods in the campaign against 
infant mortality, cancer, the venereal diseases, etc. Quite in contrast 
to the lack of success which had characterized the earlier efforts to 
reduce infant mortality by concentrating attention on the sick babies 
the application of the preventive educational methods quickly yielded 

1 This activity was initiated by New York City in 1876, when a staff of physicians, 
known as the "Summer Corps" was organized. The plan was followed each summer 
for many years. 
47 



738 PUBLIC HEALTH EDUCATION 

favorable results. In fact, the contrast was so pronounced that health 
education came to be recognized as an important function of health 
authorities. 

HEALTH EDUCATION IN THE SCHOOLS. 

Health education, like all education, is best begun at as early an 
age as possible. So far as organized health education is concerned it 
should begin with the entrance of the child in school and should con- 
tinue throughout the entire school life. In the lower grades simple 
instruction is given in cleanliness of the hands, face and teeth, the 
importance of covering the mouth when sneezing and coughing, the 
use of handkerchiefs, spitting on the floor, etc. In addition to this it 
is well to discuss the needs of pure food, pure water and fresh air, the 
influence of alcohol and tobacco. In the more advanced grades there 
should be simple instruction in the spread of disease through the 
exchange of secretions; the value of fresh air and sunlight illustrated 
by plant life; elementary instruction in food and nutrition, street 
accidents, first-aid and the influence of alcohol and tobacco. 

In the first three years of school the pupil should be told to do 
things without emphasizing the reasons therefore. Each topic should 
be related to daily living and should affect daily practice. After the 
third year the pupils may use text-books; but the teacher should 
endeavor to ensure the grasp of one or two topics in a lesson and not 
try to cover too much ground. The result of the instruction should 
be tested by inspection of the pupils and by observing how well they 
have formed habits of good hygiene. Student self-governing health 
leagues may be formed with great profit, and these may advantageously 
be organized either on the street-block basis or with the class-room as 
the unit. In fact, both types of organization may exist side by side. 

In the high schools the courses in science and biology offer exceptional 
opportunities for instruction in health matters. Here can be taken up 
certain important disease germs, such as those of diphtheria, typhoid 
fever and tuberculosis, milk as a food, bacteria in milk, food and nutri- 
tion, food supervision, water supply, sewage disposal, etc. Interest in 
the work of the health department can be aroused by the courses in 
civics. 

In this connection attention is called to the program of physical 
training prepared by the Military Training Commission in New York 
State for use in the elementary and secondary schools. 1 Due largely 
to the breadth of view of the State inspector of physical training, Dr. 
Thomas A. Storey, "physical training" as provided for this program, 
is construed as covering (a) individual health examination and personal 
health instruction; (6) instruction concerning the care of the body 
and concerning the important facts of hygiene . (recitations) ; (c) 
physical exercise as a health habit, including gymnastics, elementary 
marching and organized supervised play, recreation and athletics. 

1 Under Iho authority of Chapters 500 and §67, Laws of 1916, New York State. 



HEALTH EDUCATION IN THE SCHOOLS 739 

The educational possibilities of such a program are great. As adopted 
by the Board of Regents it calls for a total of six hours a week of school 
time on the part of each child in all the grades in every element ary 
and every secondary school throughout the State. It provides for a 
correlation between the class-room teacher and the school medical 
inspector; provides short, refreshing setting-up drills four times each 
school day; emphasizes good posture; devotes at least one hour, and 
not more than four hours, per week to directed recreation ; includes at 
least two periods weekly, of thirty minutes each, for gymnastic drill, 
and marching, and finally provides for at least twenty minutes a week 
to recitations on care of the body and on important facts of health. 

Given a realization of the surpassing importance of good health, 
the ways in which health topics can be introduced into the school 
curriculum are practically endless. While the first point of attack is 
naturally through the formal courses dealing with hygiene and physical 
training, an alert teacher will not overlook the opportunities presented 
by the assignment of health topics as subjects in English composition, 
by health problems arthmetically presented, by a study of the health 
department under the head of civics, and by careful instruction in 
personal hygiene, under other appropriate headings. In the upper 
grades and in the high schools the preparation of simple graphs dealing 
with vital statistics offer a means of making public health problems 
a reality to the pupils. The art classes can cooperate with the health 
authorities in the preparation of posters; the domestic science classes 
can be interested in teaching the relation of nutrition to health; the 
classes in chemistry and biology are prepared to study the work of the 
health department's laboratories. 

Health officers are in danger of forgetting that many of the health 
data which they have at their fingers' ends are quite unfamiliar to 
many teachers. This is especially true of the more recently discovered 
facts, and is more apt to be encountered among teachers without 
college training and among the older generation of teachers. In 
furthering the more formal classroom instruction in health matters 
the health department should therefore see that every assistance is 
given to the teachers in the way of illustrative material, prepared 
health texts and lessons and that opportunity is offered to teachers 
and to older pupils to observe the various activities of the department 
of health. 

In addition to the more strictly educational methods just outlined, 
knowledge concerning health matters should also be imparted through 
the work of the school doctor and the school nurse. A system of school 
medical supervision which does not constantly aim to teach the pupil 
the significance of the various medical examinations and of the action 
taken as a result of such examinations is doing only a small part of its 
work. Wherever possible the work of medically examining school 
children should be so arranged that the child's parent is present. It 
is remarkable how much better cooperation can be secured in this way 
and how well this opportunity lends itself to effective health education. 



740 PUBLIC HEALTH EDUCATION 

The schools can be utilized still further in promoting health education 
for they are extremely useful as a means to reach the adult members 
of the community. To this end the schools are made the center of 
rallies, celebrations and similar ''features," and the children serve as 
carriers of health messages into the homes of their parents. The latter 
is most simply accomplished by means of printed leaflets, etc., but it 
is throwing away golden opportunities to make the children merely 
mechanical carriers of printed leaflets. Whenever possible the message 
carried by the leaflet should also be given directly to the children, in 
the form of a simple lesson, which they can understand and which 
they can then carry into the home by word of mouth. 

NEWSPAPERS IN HEALTH EDUCATION. 

While perhaps the most effective and most lasting health education 
is that acquired in childhood, adult education is highly important and 
should not be neglected. In fact, there are subjects that cannot well 
be presented to children, among them matters relating to industrial 
hygiene, venereal diseases, sex hygiene, etc. Of the various means of 
furthering health education among adults, none exceeds in influence 
the newspaper. There is still a great deal of misconception of the way 
newspapers can be utilized for this purpose, and such misconception 
often leads to unjust criticism, both of the health officers and of the 
newspapers. 

It is well to recognize that the newspaper can be used by health 
departments for two different purposes, both of them legitimate, 
namely, (1) advertising and (2) educational publicity. The service 
which advertising, i. e., mere publicity can render is often overlooked; 
in fact, now and then we hear it criticized as undignified. Yet merely 
keeping the ordinary doings of the health department before the public 
by means of news articles is of invaluable aid in enlisting financial and 
moral support for the department's activities. It is natural, too, that 
the public should like to know how its money is being spent. Experi- 
ence shows that necessary funds will more readily be voted to a health 
authority whose activities are known to the public. In a measure 
such chroniclings also have an educational value; their main purpose, 
however, may be said to consist in keeping the doings of the health 
department before the public, i. e., in legitimate advertising. 

In contrast to the preceding, newspapers can be used for the dis- 
semination of educational publicity. This is much more difficult to 
handle and requires considerable judgment, a keen sense of what 
constitutes "news" and a knowledge of local newspaper conditions. 
In this connection, however, it is well to differentiate between the 
large metropolitan newspapers and those published in smaller towns. 
In the former, space is at a premium and difficult to secure; in the 
latter, conditions are usually quite the reverse; the editor welcomes 
good readable material to fill his space. This is especially true when 
the material is supplied to him free of charge in the form of "patent 



NEWSPAPERS IN HEALTH EDUCATION 741 

insides" or "boiler plate." By this is meant material supplied in the 
form of metal castings (stereotypes), ready to put into press. A number 
of commercial "press associations" make a business of handling this 
kind of newspaper work. Copy is supplied to them in typewritten 
form, they submit proof and for a given consideration arrange for the 
publication of this material in a given number of newspapers. For 
educational work by State health departments this is a very desirable 
method of handling the newspaper activity. It has the distinct 
advantage that the text and the amount of space is absolutely in the 
control of the health department, and one knows exactly what return 
in newspaper space is being obtained for a given expenditure. 

Very few of the larger newspapers make use of ready-to-print plates, 
and this method of securing the publication of educational health 
articles can therefore not be utilized to advantage in reaching the 
people of the larger cities. These newspapers, however, may be very 
willing to make use of articles, preferably illustrated, supplied in the 
form of stereotype matrices, or "mats" as they are usually called. It 
is well to have the mat comprise an article two or three columns wide, 
or even the width of a page, and occupy a length of from four to nine 
or ten inches. A picture is almost indispensable in order to secure any 
considerable proportion of publications. These mats can readily be 
sent through the mails and they constitute an extremely convenient 
and economical means of securing the publication of articles in the 
exact form in which they are prepared. When supplied in quantity, 
say fifty mats, or over, they can be laid down in the newspaper offices 
at a cost, varying with the size, of from fifteen to twenty-five cents. 

In the large metropolitan newspapers educational articles on health 
are usually accepted most readily if they are connected with some item 
of news. At the same time it is rare even then to find extended space 
given to the educational part of the bulletin sent out. Xo matter how 
important, from the health officer's standpoint, the educational part 
of the bulletin will usually suffer extensive cuts or may be deleted 
entirely. There is really no way of avoiding this and the problem, 
therefore, becomes one of presenting the material in some other form. 
It would be a mistake, however, to believe that the large metropolitan 
newspapers cannot be utilized for educational health notes. The fact 
remains that whatever material of this kind does find publication in 
such newspapers is read by millions of people, and therefore exerts a 
very wide influence. The alert director of health publicity will know 
how to make use of innumerable news happenings about which to 
write a brief educational note. After all the frequent publication of 
short health hints in this way is probably more effective than the 
occasional publication of a lengthy health article, for many people 
will not bother reading the letter while the former can hardly escape 
being read by all. 

It is often of interest to determine how widely a given article is 
read. This can be done by means of an offer to supply something on 
request. Moreover, if one desires, it is a simple matter, by the use of a 



742 PUBLIC HEALTH EDUCATION 

key, to determine which particular form of announcement brought 
the response. For example, one may be in doubt concerning the 
necessity of preparing copy for certain foreign language newspapers. 
A few tests of this kind will soon supply a reliable answer. 

While on the subject of foreign language newspapers it may be 
pointed out that while English copy is extensively utilized, better 
results are obtained if material is already translated. Unless, however, 
a trained, fluent writer is available it is better to send English copy. 

A word now as to the preparation of a press bulletin. If a health 
department plans to make rather extensive use of press bulletins, or if 
the number of newspapers served is considerable, it is well to employ 
a printed blank form. 

The bulletin itself may be either typewritten, multigraphed or 
printed. If it is typewritten care should be taken that the carbon copies 
supplied are legible. For a moderate-sized press service one can make 
as many as fifteen to twenty legible carbon copies by the employment 
of what is known in the trade as "onion paper." For numbers larger 
than this it is well to make use of a multigraphed reproduction. When 
the number of copies to be sent out reaches several hundred it is 
advisable to consider printing the bulletin. Printed press bulletins 
are extremely useful when limited funds make it impossible to send 
out bulletins very frequently, but where, nevertheless, a large number 
of publications are to be served. Under these circumstances the type 
of bulletin technically spoken of as a "clip sheet," employed, for 
example, by the American Society for the Control of Cancer, by the 
United States Public Health Service and by the American Medical 
Association is to be recommended. This usually consists of a large 
printed sheet containing a number of articles, some long, some short, 
some simple, others more technical, thus permitting a selection to be 
made by the editor to whom they are sent. Effective work can be done 
by supplying a considerable number of short items — two and three 
lines each. These are spoken of as "fillers," and are welcomed in all 
newspaper offices. 

In writing the press bulletin it is advisable to follow a custom 
common in most newspaper offices and tell the story at least twice, 
first in condensed form in the opening sentence or paragraph and then 
in more detail. Sometimes still further elaboration can follow this. 
The advantages of this method are several. Even if the entire bulletin 
is printed, many readers will not pass beyond the opening paragraph, 
perhaps only a few will carefully read the entire article. If lack of 
space make it necessary to cut the article this is easily done without 
mutilation. Even if only the opening paragraph is printed, something 
will have been accomplished. 

In giving to the newspapers information constituting a news item 
it is imperative that the information be given to all the newspapers. 
There must be no favoritism. In a large city most of the newspapers 
receive the service of some news agency, and when this is the case it 
will often suffice to give the news items merely to this agency. 



NEWSPAPERS IN HEALTH EDUCATION 743 

For State or national work one should make sure that the several 
large news gathering agencies, Associated Press, United Press, Inter- 
national News Service, etc., are supplied with the bulletin. While 
the ethics demand that the original news bulletin be supplied to all 
the prominent newspapers or news-gathering agencies, they also 
demand that any information solicited by further inquiries on the part 
of some one newspaper reporter be regarded as belonging, for the 
time, to that reporter. The health officer should not volunteer such 
information to a rival reporter, though, on the other hand, he should 
not withhold it if direct inquiry is made. Careful observance of the 
just rights of the reporter and recognition of his duties to his news- 
paper will quickly make him not only a most valuable educational 
factor but also a friend who can be trusted. 

Careful judgment should always be exercised as to publishing names 
of individuals in connection with health department activities. For 
example, an inspector finds a lot of spoiled food on the premises of a 
butcher. He promptly denatures the stuff and serves a summons to 
court on the owner of the establishment. Is the name of the butcher 
made public? A localized outbreak of typhoid fever is traced to a milk 
supply sold from the wagons of a given dealer. Is the name of the 
dealer given to the press? 

In deciding on the course to pursue one should bear the following in 
mind: The fact that the spoiled food was found on the butcher's 
premises does not in itself prove the butcher a scamp, deserving of 
publicity and odium. He may have a reasonable and convincing 
explanation and may be wholly innocent of wrongdoing. Moreover, 
if an innocent person is thus held up to public scorn he might have 
good grounds for a libel suit. It was the writer's practice, in handling 
the publicity work of the New York City Department of Health, never 
to publish names in these cases until after a conviction in court. Once 
that had occurred, there was no reason for withholding the name of 
the one convicted ; in fact, there was every reason for giving the matter 
wide publicity. 

In the case of the milk dealer, whose milk carried typhoid infection, 
no name should ordinarily be mentioned unless one could prove that 
the dealer had knowingly and grossly violated sanitary regulations. 
In most cases of this kind, however, the dealer is the victim of circum- 
stances, and he will be far more ready to cooperate if he knows he can 
expect just treatment at the hands of the health authority. 

In addition to the various educational items, and to the publicity 
news notes sent to all the papers in practically identical form, most 
newspapers will make use from time to time of feature stories. These 
are not news items and a given feature story is supplied to only one 
particular paper. In fact, it is not good form even to let other writers 
know just what feature stories are in preparation or to give out identi- 
cal material to several papers. As a rule, illustrations are welcome. 
If these are in the form of photographs, glossy prints should be sup- 
plied. Simple graphs are sometimes accepted. The style of these 



744 PUBLIC HEALTH EDUCATION 

feature stories varies: sometimes they are wanted in the form of an 
interview with the Commissioner of Health or some other prominent 
health official; often the editor prefers a human interest story. A 
Large number of special writers make a business of writing such articles 
for magazines, newspapers, etc., and they should be encouraged to 
come to the Health Department for material. 

An excellent vehicle for the dissemination of health information is 
that furnished by a "Health Column," supplied to newspapers and 
conducted on the question and answer plan. Such a column, to be 
sure, entails a considerable amount of labor, but when properly 
managed constitutes a powerful educational factor. 

Following is a sample of the daily health column conducted by the 
U. S. Public Health Service. It will be observed that the material 
consists of a short health article, together with several answers to 
questions from correspondents. By selecting suitable questions for 
reply through the column, a large reading clientele can be interested 
in matters pertaining to health and preventive medicine. 

Uncle J$am,_M . D. 

A daily health column conducted iiy the United States Public Health 

Service 
BY DIRECTION OF ft L PERT BLUE 

Surgeon General, U. S. Public Health Service. 



DYSPEPSIA, 



Sufferers from dyspepsia should 
therefore seek competent medical ad- 
Dyspepsia is onlv a symptom of dis- vj ce. and have the doctor find the 
lase, and is often not due to disease ca " se of the symptoms. 

• f the stomach itself. QUESTIONS AND ANSWERS. 

Dyspepsia may result from nerv- ^ Ig whooplng cough a dange r- 

ousness. Emotional dyspepsia is, very ous disease? 

Common. Everyone knows how bad A Decidedly yes, especiaUy in 

news or worry will interfere with di- young . cnildren , The greatest danger 

gestion.and be- followed by distress of spreading the disease Is In the first 

after a meal. week or two. Do not let your chil- 

1 Consumption is often accompanied dren play with other children who 

by stomach trouble; in fact, this may have a suspicious cough. If there is 

be the only complaint made by a, pa- whooping cough In your neighbor- 

tiont suffering from this disease. hood try and keep close watch over 

Disease of the heart especially such your children, especially when* the? 
»<* causes stagnation of blood in che play with other children, 
abdominal organs; of the liver, such Q. Who can give me confidential 
as is: produced by alcohol or gall- advice on veneral disease. I have not 
stone;' of the intestines, particularly enough money to undertake the 
if there Is constipation or obstruction treatment if it costs too much, 
of the free passage of the bowel con- A. Apply to your cfty, or state 
tents; of the kidneys, as in chronic health officer. Very probably there is 
inflammation of those organs, where a clinic in your city where free treat- 
the waste products of the body are me.nt is given. Helpful leaflets may 
fiot fully eliminated; of the brain, as be obtained by writing to the United 
where there is a tumor or inflam- States Public Health Service, Veneral 
matlon of the cerebral membranes— Disease Division, 228 First St., Wash- 
fell give rise to stomach symptoms. ington, D. C.__ 



NEWSPAPERS IN HEALTH EDUCATION 745 

The use of paid advertising space for health department publicity is 
generally open to criticism. Now and then it may be advisable to 
resort to this method of securing newspaper space, but even then the 
propriety of thus using public funds may be questioned. This objec- 
tion is not entirely overcome by having the advertisement paid for 
by some private individual or civic organization. 



;— -— i/ncie Stun, M. D<, Gives"- — — 

! Health Advice 

I 

Written by Experts Under Direction 

of Dr. Rupert Blue, U. S. Public 
Health Service. 



Questions and Answers 

3-: I was discharged from the army eight months 
ago and, despite all I can do, cannot get rid of an 
annoying reminder of my service, namely, cooties. 
What would you advise? 

A.: You probably are entitled to free medical care 
under th* provisions of the war risk act. Please send 
me your name and. address and I will see that the mat- 
ter is referred to the proper authorities. 



Q.: I am a high school student, studying biology. 
Can you tell me all about sewage disposal? 

A.: To do so would require a book. If you will send 
me your name and address I will send you some help- 
ful pamphlets, which will probably give you all the 
information you desire. 



Q.. What is "winter cholera?" Is it Asiatic cholera? 
How is it spread? 

A.: The term is loosely used. Mostly it is applied 
to a diarrheal disease caused by drinking infected 
water. Sometimes investigation has shown it to be 
simply an epidemic of typhoid fever. Such water-borne 
epidemics are more apt to come in winter and spring 
as a result .of rains and freshets polluting water sup- 
[ plies. 

In many communities a task of no little magnitude is that presented 
by the misleading medical propaganda of the patent medicine faker 
and the charlatan. The income derived by certain newspapers from this 
class of advertising is enormous and will rarely be given up except 
under some form of compulsion. Here and there, to be sure, news- 
paper publishers will recognize the advantage gained by excluding such 
advertisements, and when this occurs a flank attack can be conducted 
against these newspapers which still carry the objectionable advertising. 
In this connection it may not be amiss to call attention to a vicious 
form of contract employed by many of these advertisers. This pro- 
vides that the contract to advertise becomes void if any legislation is 



740 PUBLIC HEALTH EDUCATION 

passed inimical to the interest of the advertiser. It is clear that this 
almost automatically causes the influence of the newspapers handling 
this form of advertising to be exerted against any legislation intended 
to control or prohibit objectionable patent medicine advertising. It 
is well to dwell on this fact when addressing the general public on the 
patent medicine evil. 

Before leaving the subject of newspapers in health education it 
may be well to call attention to the surprising value of personal contact 
established between the health officer and newspaper editor. Such a 
contact will serve to teach the health officer what constitutes "news," 
what kind of material will secure publication and what form is best 
adapted for newspaper presentation, In addition to its value to the 
health officer such contact will also be of assistance to the editor, for 
it will serve to make him much more directly familiar with the work 
of the health department and will make him more sympathetic toward 
the work to be undertaken by the health officer. 

Periodic Publications. — In the larger cities the publication of a 
health bulletin will be almost indispensable. In the. smaller cities and 
towns such a bulletin may also be made a valuable educational agent, 
but to a large extent its place can be taken by the local newspaper. 

There are several reasons why the larger cities should issue health 
bulletins; perhaps the most important is the fact, already mentioned 
in speaking of metropolitan newspapers, that it is difficult to get the 
newspapers to devote much space to merely educational articles and 
practically none whatever to statistical tables. Another reason is 
the valuable bond established by the bulletin between the health 
department and the readers of the bulletin. Still another is the fact 
that the bulletin can be made a convenient permanent record of the 
health department's activities. Finally, the bulletin can serve as a 
valuable text in health teaching in the schools. 

In the preparation of such printed bulletins one should have clearly 
in mind the group of people to whom the bulletin is to be distributed. 
It is practically impossible to prepare a bulletin that will be interesting 
and instructive to all elements of the community. If the readers 
constitute what may be termed the intellectual leaders of the com- 
munity, city officials, school principals and teachers, physicians, 
clergymen, prominent business men, etc., it is important not to have 
the bulletin look like a health primer. On the other hand, if a large 
edition is to be distributed to the masses one must use extremely simple 
forms of expression and employ numerous pictures. In very large cities 
health departments may find it profitable to publish both kinds of 
bulletins. By sending the more technical bulletin regularly to every 
physician, school principal and druggist in the city the health depart- 
ment can obtain a large amount of cooperation which otherwise is 
lacking. 

In the preparation of text for these bulletins it is important not to 
publish ponderous scientific articles whose appeal, after all, can only 
be limited. Tables may be used in bulletins issued to a selected, 






NEWSPAPERS IN HEALTH EDUCATION 747 

intelligent group of readers, but even then they should be of the 
simplest kind. For the purpose of making simple statistical compari- 
sons the use of graphs is greatly to be recommended. The expense of 
reproducing such graphs in the form of line cuts is small. For an 
excellent description of graphic methods the reader is referred to the 
very helpful and suggestive book by Brinton. 1 

Fully as important as the text of the material published in these 
bulletins is their typographical make-up. The type employed should 
be selected with care. Eight-point or ten-point type, set single leaded, 
with headings in heavy face capitals and subheadings in heavy face 
upper and lower case make a pleasing appearance. Subordinate matter 
can be set solid or in smaller type. Two narrow columns on the page 
are perhaps a little easier to read, but the advantage is hardly suffi- 
cient to compensate for the disadvantages when it comes to make-up, 
i. e., arrangement of material on the page. This drawback is especially 
felt when it is necessary to include tables which are wider than a single 
column. 

Distribution of the Bulletins. — The question of distributing the bulle- 
tins will have to be answered entirely according to the class of people 
which one desires to reach. In distributing large editions of popular 
bulletins prepared to reach the masses directly one will find the public 
schools, boy scouts, Junior Police and similar organizations, con- 
venient and effective distributing agents. It is rare, however, to have 
periodic bulletins available in sufficient quantity to distribute so 
lavishly. Most health departments mail their periodic bulletins, and 
when this is done one will naturally desire to secure the second-class 
mailing privilege. So far as State boards of health are concerned their 
periodic publications are admitted to the second-class mailing privilege 
under the Act of August 24, 1912. The same is true of publications 
of a strictly scientific character issued by an incorporated institution of 
learning. City boards of health, however, cannot mail their publica- 
tions as second-class mail under the provisions of this act. In order 
to secure the second-class mail privilege, city boards of health can make 
application under the Act of 1789, which provides for periodic publi- 
cations sent to a bona-fide list of paid subscribers. It may be well to 
remember, however, that monthly publications, even when they have 
been admitted to the second-class mail privilege, must pay regular 
postage rates (for printed matter), if they are addressed for delivery 
within the limits of the post office of mailing. This does not apply to 
weekly publications. 

In the work of State health departments, effective aid can be given 
to local communities by supplying the latter with a special edition of 
the State health bulletin. This is modeled on the plan devised by the 
writer and successfully pursued by the New York City Department of 
Health in providing a local monthly health bulletin for twenty different 
sections of the city. Each section received an edition of five thousand 

1 Graphic Methods for Presenting Facts by Willard C. Brinton, The Engineering 
Magazine Co., New York, 1914. 



748 PUBLIC HEALTH EDUCATION 

copies of a four-page monthly bulletin, and while the second, third and 
fourth pages were identical in all twenty bulletins the first page was 
individual and carried a distinct title, together with health notes per- 
taining to that particular section of the city. 

In addition to periodic publications, such as a weekly, monthly or 
quarterly bulletin, it is desirable always to have on hand a consider- 
able supply of health leaflets in great variety. They are needed in con- 
nection with many other activities, school work, baby health stations, 
industrial hygiene, tuberculosis campaigns, work against flies, mos- 
quitoes, etc. Such leaflets should be attractive but inexpensive, for 
they are intended for wide distribution. Placards and pictures bearing 
on most of the same topics are extremely useful in calling public 
attention to some special activity; they can be displayed in store win- 
dows, posted in shops and factories, on school bulletin boards, fences, 
etc. Attention has already been called to the making of picture 
poster designs by students in the art classes in the high schools. It 
is a plan possessing many advantages and should not be neglected. 

In the making of posters a number of considerations deserve atten- 
tion. It needs no explanation to show that four-color lithographs are 
far more expensive than posters in one color from a zinc cut. A careful 
study of some of the posters used in connection with the war drives 
and the various Liberty Loans will convince any unprejudiced observer 
that some of the most effective posters were printed in only one color. 
To be sure, they were usually not black on white but rather brown 
on buff, or dark blue on gray, or some similar pleasing combination 
which gave practically a two-color effect. 

^Yhile there are some advantages in printing the posters on heavy 
stock (light cardboard) the distribution and the expense when this 
material is used usually presents great difficulties. It is generally 
advisable, therefore, to print posters on heavy paper (sixty pounds) 
and so make it possible to distribute the posters by mail, either in the 
form of a soft roll or in a mailing tube. The usual sizes for such poster 
are 40 inches x 30 inches, 30 inches x 20 inches, or 20 inches x 15 inches. 

In rural work, where it is planned to use posters outdoors, muslin 
will be found preferable to paper bill boards. Metal signs may also 
be used, but the expense is considerable. 

So far as lettering is concerned it is well to remember that the mes- 
sage on a poster should be so short as to be taken in almost at a glance. 
An overabundance of text usually causes the reader to pass on at once. 
The same is true of the excessive use of capital letters. For excellent 
suggestions on lettering see Routzahn's book on Exhibit Planning 
and Brinton's work on Graphic Methods. 

EXHIBITS. 

An educational vehicle of great power in selected cases, but one whose 
proper utilization requires not only study and preparation but also, 
usually, a considerably outlay of time and effort, is the health exhibit. 



EXHIBITS 749 

The advantages of this method of popular appeal and education are 
several ; 

1. An exhibit can be made so striking as to attract the attention of 
people who would not go to a lecture or read a pamphlet, or otherwise 
become informed on the subject exhibited. 

2. It is a quick method of presentation, gives ideas in a form readily 
grasped and appeals to all sorts and conditions of men. 

3. It brings people together and facilitates an interchange of talk 
concerning the subject of the exhibit. Moreover, an exhibit demon- 
strator can answer questions while a pamphlet can deliver only one 
message. 

4. It makes possible the focussing of public attention on one idea 
during a brief period to such an extent that the subject becomes a 
live issue for community discussion. 

Realizing both its advantages and its limitations the public health 
exhibit, in some form or other, may well be utilized in every organized 
campaign of health education. In the case of State health depart- 
ments or other organizations called upon to supply exhibit material 
for many different localities it is well to remember that great damage 
usually results from careless handling and packing, installing and 
shipping of exhibit material from place to place. This applies espec- 
ially to so-called "three dimension material," i. e., models and the 
like. The glass of framed pictures is very readily broken and the same 
is true of a display of laboratory apparatus. For these reasons, port- 
able exhibits are most satisfactorily made largely in the form of printed 
poster panels, and this material is supplemented, as occasion offers, 
by the three dimension material obtained locally. 

Where an exhibit is to be installed for a considerable period, say for 
from one to six months, a great deal of interest can be aroused by the 
use of models making use of some movable device. A number of effec- 
tive models of this kind are now supplied through commercial channels. 1 

In a small community it is surprising how much can be accomplished 
by well-planned exhibits occupying less than a single show window 
of some prominent store on the main street. An effective exhibit of 
this kind was utilized by the writer in connection with an antimosquito 
campaign. It consisted essentially of two panels bearing photographs 
and legends describing antimosquito measures. Between these panels 
was the main attraction, namely, an aquarium filled with water swarm- 
ing with living mosquito wrigglers. An electric light behind the 
aquarium served to make the exhibit more conspicuous. 

In connection with a poster contest among high-school children 
a well-attended exhibit can usually be arranged by displaying all the 
posters received during the competition. 

During special feature campaigns considerable aid can be obtained 
by having the local merchants dress their show windows in line with 
the subject being featured. Thus, during baby week dry goods stores 

1 Educational Exhibition Company, Custom House Street, Providence, R. I. 



750 PUBLIC HEALTH EDUCATION 

make a special display of baby clothing, layettes, cribs and nursery 
fittings; drug stores make a display of nursing bottles, baby scales, 
pasteurizers, baby powders and the like; jewelry stores feature baby 
spoons, baby pins, teething rings and silver rattles. During a clean-up 
campaign hardware stores displayed rakes, garden hose, garbage 
buckets and paint; grocery stores display soaps, washing powders, 
ammonia, and scrub brushes; drug stores display disinfectants, vermin 
killers, fly papers, soaps and the like. A little thought will show 
numerous ways in which the campaign can thus be assisted by the 
local merchants. 

LECTURES. 

Within a restricted sphere of usefulness popular health lectures are 
of distinct value in public health education. Many of the lectures at 
present given by health agencies are almost worthless. The mistake 
is frequently made of inviting as lecturer someone who while an 
authority in his special field, is without any qualifications as a public 
speaker. As a matter of fact, for a popular health talk it is far easier 
to coach a good public speaker so as to be familiar with his subject than 
it is to get a specialist to deliver a good popular talk. Another common 
mistake is to have too long a lecture and make no provision for a dis- 
cussion and questions. Twenty minutes is enough for the lecture 
proper, and then there should be at least twenty minutes more of 
discussion and questions. It will not do to leave the latter to chance. 
In order to obtain the best results, even after a good lecture, it is well 
to provide for a few in the audience prepared with questions and topics 
for discussion.. This will often stimulate others to participate in the 
meeting and will help to accomplish the object of the lecture. 

When stereopticon pictures are shown the time must be extended, 
though even here it is not uncommon to find the audience imposed 
upon by too long a presentation. Forty minutes for the illustrated 
lecture, with the usual period for discussion and questions, is the usual 
safe limit. 

With the widespread use of moving pictures it may not be amiss 
to utter here a word of caution. Unless one has a moving picture which 
can stop with the picture on the screen it is a mistake to attempt to 
give a lecture while showing a moving picture. The combination is 
most distracting and fails utterly to convey any clear message. With 
the fire-proof film, such as are shown, for example, in the Pathescope 
machine, the picture can be stopped at any one point, and then with 
the picture at rest on the screen a few remarks can be made. Then the 
showing of the picture is resumed. 

In this connection attention may be called to the fact that stere- 
opticon slides on health topics may be borrowed from various State and 
local health departments, from the United States Public Health Service 
and from a number of organizations engaged in health work (National 
Association for the Study and Prevention of Tuberculosis, American 



MOVING PICTURES 751 

Society for the Control of Cancer, American Social Hygiene Associ- 
ation, American Museum of Safety and others). 

So far as possible, all the slides should be supplied with legends which 
will appear on the screen. There are many times when it will be desired 
to use slides without a lecturer, and when this is the case it is imperative 
to have a descriptive legend which will be part of the picture flashed 
on the screen. By the use of slides with proper legends an interesting 
exhibit can be conducted at night in store windows by the use of lan- 
terns which display the set of slides seriatim. Such an apparatus, 
known as a "stereomotorgraph," is also an attractive feature of a 
health exhibit. 

In conducting feature campaigns it is sometimes desirable to make 
use of lantern slide announcements repeatedly flashed on the screen 
in moving-picture theaters. Or it may be desired to have moving- 
picture theaters flash certain standing announcements for a considerable 
period, such as " Cover up your coughs and sneezes," or "Please do 
not spit on the floor in public places." Whenever slides are to be 
used repeatedly in this way, the breakability of glass slides must be 
borne in mind and the use of brass stencil slides or of mica slides may 
be considered. When identical slides are used in considerable number, 
their expense is much reduced from what is ordinarily charged. At the 
present time, for example, identical slides in quantity of ten or more can 
be had for about ten cents apiece. 

MOVING PICTURES. 

As one contemplates the present tendencies in moving pictures, one 
one cannot help but notice the enormous vogue of the so-called feature, 
usually a five- or six-reel drama which occupies nearly one and one-half 
hours of the spetactor's attention. Recent health films have appar- 
ently copied this plan and now one sees a number of health films, e. g., 
on venereal diseases or tuberculosis, whose showing requires four, 
five or even six reels. Practically all of these pictures tell a health 
story in the form of a human interest drama, usually a love story. 
The writer seriously questions the value of this form of teaching. In 
most instances the spectator recalls mainly the love story and forgets 
all about the lesson which is really the chief theme of the picture. The 
writer is convinced that far more effective health teaching can be 
carried on by means of simply descriptive and informative moving 
pictures, usually a single reel in length, often even better, "split reels," 
i. e., about half a reel. These tell their story in from seven to fifteen 
minutes and give simple health facts in a form easily understood and 
remembered. Such pictures can be purchased from a number of pro- 
ducers, among them National Motion Pictures Corporation, Indian- 
apolis, or they can be rented from the Beseler Educational Film Com- 
pany, 71 West 23d Street, New York. 

It is perhaps natural that health officers and others conducting 
educational campaigns should seek to show such moving pictures as 



752 PUBLIC HEALTH EDUCATION 

part of the health mass meeting or exhibit material. In general, how- 
ever, it will be found that this plan presents a number of difficulties. 
Thus, in most States there are definite laws governing the construction 
of places where moving pictures are shown. These laws relate to fire 
exits, seating arrangements, stairways and the like. Moreover, they 
usually prescribe the use of fireproof booths for the moving-picture 
machines and operator. Practically all of these difficulties can be 
overcome if the picture is shown at an established moving-picture 
theater. For this reason it has been the practice of the writer to loan 
health films to such theaters and have them shown as part of the 
regular program. With only a single reel at a time showing perhaps a 
different health reel each day for a week, or on the same day for several 
successive weeks, a large amount of educational propaganda can be 
conducted with a minimum of effort. There is another advantage in 
this form of procedure : When showing a number of health movies at a 
health exhibition conducted by the health authorities or other welfare 
agency one deals with a group of spectators who are usually unappre- 
ciative and inattentive because they are seeing a free show. This is 
not the case when the picture is shown in the regular program of the 
moving-picture theater, for there the spectators have paid an admission 
fee and want to see all that they can. Psychologically it is usually poor 
policy to give free health movies. 

The objection just mentioned has been considered by the various 
producers of the feature films on health topics. Among these are the 
well-known pictures "Fit to Win" and "Open Your Eyes," dealing 
with venereal diseases. Both of these are features, that is, five- and 
six-reel pictures, and are being exhibited on the same basis as other 
commercial pictures. They are not shown free, and they have appar- 
ently been very successful commercial undertakings. It must, however, 
be remembered that these deal with six matters, in which interest is 
very great. It is extremely doubtful whether any other health topic 
could be handled on this basis. The writer believes that an undiluted 
health story, in a reel or less, offers a far less expensive and fully as 
effective vehicle for health education. 

In order to overcome the difficulties attending the showing of ordi- 
nary motion pictures a number of concerns have prepared n on-inflam- 
mable pictures to be shown by means of small portable machines 
(e. g., the Pathescope) in school rooms, assembly halls, factories and 
the like. Unfortunately this requires the use of special films, and these 
are not always readily obtainable. 

PHYSICIANS. 

It is a regrettable fact that a large part of the physicians, especially 
those in the remoter rural districts, are greatly in need of health 
education. It is not uncommon to meet physicians who practice 
medicine along the lines taught over forty years ago who do not believe 
in the mosquito theory of malaria and who do believe in sewer gas, 



PHYSICIANS 753 

the spread of disease by fomites and other relics of a bygone age. 
But even among physicians whose purely medical and surgical knowl- 
edge is fairly abreast of the times it is not uncommon to find many 
who do not realize how imperative it is that all physicians should 
become health teachers. These consider their work done when they 
have examined the patient, made a diagnosis and given suitable direc- 
tions for taking the prescribed medicines. Yet how well do we not 
know that this is only half the duty performed. What is the patient's 
occupation? Just what duties does this involve? Under what con- 
ditions are they performed? These and a host of other questions would 
often lead to a discovery of underlying causes of the patient's illness, 
only temporarily relieved by the prescription so quickly written out. 
Moreover, and this failure is equally common, has the physician 
inquired carefully into the family conditions? In the case of a com- 
municable disease, has he taken all steps necessary to safeguard all 
members of a family and the community as well? Has he demon- 
strated exactly how bedside hygiene is to be carried out? In case of a 
reportable disease, or even of such a condition only suspected, has he 
notified the health authorities? 

Last, but perhaps the most important of all, does the physician take 
an active interest in community health and welfare? Does he know 
that the drinking water is safe? Has he pointed out the danger of 
shallow wells in built-up sections of the town? Has he familiarized 
himself with the milk supply? Has he advocated pasteurizing the milk 
supply? Has he ever visited the public school and taken note of the 
sanitary conditions there prevailing? In short, the physician should 
feel it a responsibility to act as one of the health guardians of the com- 
munity. This, to be sure, is an ideal condition still far, far away. 
But health officers should endeavor to enlist the interest of all the 
physicians in the community and secure their active cooperation in 
promoting the health of the people. How can this be accomplished? 
Much can be accomplished by placing the physicians on the mailing 
list to receive bulletins published by the State Health Department. 
In addition to this the health officer can secure cooperation through 
regular attendance at the meetings of the various medical societies 
and by the judicious organization of advisory committees on various 
phases of health work. 

The holding of health institutes constitutes another excellent means 
of reaching the physicians. Such institutes may consist, for example, 
of courses of instruction in contagious diseases (conducted at the 
contagious disease hospital) or in the administration of salvarsan (at 
the venereal clinic) or in the diagnosis of pulmonary tuberculosis 
(at the tuberculosis clinics) or in infant-feeding (at the baby health 
stations). For all of these the health department will probably have 
excellent facilities available. Needless to say, such courses should be 
free to all registered physicians. 

Under certain conditions a more lasting impression can be made by 
strict law enforcement and the exaction of a penalty. Thus in the 
48 



754 



PUBLIC HEALTH EDUCATION 



efforts of the health officer to secure more complete birth registration, 
experience appears to show that some physicians will not regularly 
report their births unless compelled to do so by fear of a penalty 
for failure to comply with the law. The example of New York City, 
where birth registration is almost complete, shows what can be 
accomplished by prosecutions of all offenders. Law enforcement must 
therefore be classed as an important educative factor. 

FEATURE CAMPAIGNS. 

An effective method of arousing public interest in health matters 
is to set aside some one day or, perhaps better, a week to be devoted 
to some one phase of public health activities. Care must, however, 
be taken not to overdo the matter, for the novelty soon wears off, and 
much of the success of these feature weeks comes from their novelty. 
Examples of successful campaigns of this kind are a baby week," 
"mosquito week," "clean-up and paint-up week," "tuberculosis week," 
"health promotion week." 

As one surveys the field of activities in this direction it is clear that 
many of the campaigns conducted among these lines have been suc- 
cessful enough so far as immediate interest and activity was concerned, 
but it is a question whether all or even many of them have led to lasting 
constructive results. As a matter of fact every such campaign should 
seek to effect a definite constructive object. Thus a "baby week" 
might have as its object the establishment of a baby health center, a 
health promotion week the establishment of a system of public health 
nursing, a mosquito week the drainage of certain bit of swamp land, 
etc. Failing such a constructive result, much of the effort spent is 
wasted. The activities to be undertaken in connection with such 
feature campaigns are of almost endless variety. Some idea of this 
kind of work can be gained from a perusal of the following helpful 
program issued by the Illinois State Board of Health in connection 
with its recent "health promotion week." 



DISPENSARIES AS EDUCATIONAL CENTERS. 

One vehicle of public health education which is still very much 
neglected is the dispensary. These institutions are peculiarly well 
adapted to undertake this important work. It is surprising to see, 
for example, how little use is made of the excellent display space 
afforded by the walls of the waiting room and corridors of the average 
dispensary. The patients visiting the dispensary are surely in a most 
receptive mood and would undoubtedly be greatly benefited by a 
display of pictures, charts, models and other exhibit material bearing 
on their condition or on health, generally. Even so careful a student 
of the dispensary as Dr. Michael, of Boston, makes absolutely no 
mention of this phase of the dispensary's work. 






SUGGESTED READING 755 

In addition to the display of the pictures, charts and exhibit material 
on the walls of the waiting room there should be an ample supply of 
simply written leaflets of instruction covering practically the entire 
field of medicine. Certain general leaflets of instruction should be 
given to every patient; others should be given according to the patient's 
illness. A beginning has been made by a number of dispensaries 
which now issue to their patients printed instructions regarding the 
precautions to be observed and the diet and general regimen to be 
followed. It is perhaps out of the question for many of the smaller 
and even moderate-sized dispensaries to undertake the preparation 
and printing of the leaflets here suggested. This is all the more reason 
why some central authority, such as the State Health Department, 
should take up this matter as part of its educational work and provide 
such pamphlets at cost. 



DISPENSARY CLASSES. 

There is another important phase of educational work which can be 
carried on by dispensaries, and that is "class instruction," In fact, for 
some of the more prevalent diseases and conditions, such as tuber- 
culosis, heart disease, malnutrition, infant hygiene and the like it is a 
great waste of effort to attempt to give very much individual instruc- 
tion to patients. Besides the economy of time and effort there are 
distinct advantages in collecting the patients into classes and giving 
them class instruction. This comes from the discussion of the problems 
naturally presented by the various patients and by the questions which 
they are encouraged to ask. Moreover, there is the stimulation of 
example set by the more earnest of the patients. 

This form of instruction has already been utilized with great success 
among tuberculosis patients, where, in fact, it originated, and more 
recently in child hygiene, malnutrition and heart disease. 



SUGGESTED READING. 

Routzahn: The A. B. C. of Exhibit Planning. Russell Sage Foun- 
dation, 1918. 

Brinton: Graphic Methods, The Engineering Magazine Company, 
New York, 1914. 

Syllabus on Hygiene for Elementary Schools, C. Ward Crampton, 
New York City Board of Education. 

Program of Physical Training, by Thomas A. Storey, New York 
State Department of Education. 

Moree: American Journal of Public Health. (Articles on Publicity.) 

MacNutt: Manuel for Health Officers (Chapter X, Publicity), 
Wiley & Sons, 1915. 



750 PUBLIC HEALTH EDUCATION 



COOPERATION AND ASSISTANCE. 

The following official and non-official agencies may be counted on 
for assistance and cooperation in activities relating to public health 
education: 

State Health Authorities. 

United States Public Health Service. 

Federal Children's Bureau. 

U. S. Bureau of Education. 

U. S. Department of Agriculture (several bureaus). 

U. S. Bureau of Census (birth and death registration). 

U. S. Bureau of Mines. 

American Society for the Study and Prevention of Tuberculosis. 

American Society for Control of Cancer. 

American Safety Council. 

American Red Cross. 

Russell Sage Foundation. 

National Committee for Prevention of Blindness. 

National Child Welfare Committee. 

National Child Health Organization. 

Clean-up and Paint-up Organization (St. Louis). 

National Child Labor Committee. 

Metropolitan Life Insurance Company. 

Prudential Life Insurance Company. 



CHAPTER XXVIII. 

MENTAL HYGIENE. 
By AUGUST HOCH, M.D. 

The mere fact that in a book on hygiene the desirability is felt to 
have a chapter on "mental hygiene" is a very encouraging indication 
that in recent years the importance of mental disorders as a public 
health problem is getting more and more appreciated. It is necessary, 
however, to point out at once that the clean-cut indications for pre- 
ventive medicine which — thanks chiefly to the remarkable advances 
in bacteriology — we are accustomed to associate with the term hygiene 
are present in only 20 to 30 per cent, of the cases that enter our hospitals 
for the insane, namely, in those chiefly in which syphilis and alcohol are 
the essential causative factors. But in a large group of mental dis- 
orders the essential causes seem to be constitutional. This group 
comprises not only patients who come to hospitals for the insane but 
also a great many persons to whom the term insanity — a term of more 
legal than medical significance — is never applied. It is natural that 
where the chief causes are constitutional, the indications for preventive 
medicine are not so simple and clean-cut as they are in cases in which 
the causes are more external. While this very fact may tend to dis- 
courage one from any endeavors in the way of prevention, the con- 
scientious psychiatrist will always again be inspired by a conviction 
that, intricate as the problem may be in such cases, it is after all possible 
to take in hand an individual and, armed with extensive experience, 
to teach that individual a manner of living which will help to safe- 
guard him from disturbances of his mental equilibrium. But it is 
precisely because there exists such a complexity of individual factors 
and because much in our experience is not yet formulated that it is so 
difficult to give anything like general rules or anything like an exhaus- 
tive account. In this short chapter I propose, therefore, when we come 
to those more intricate problems, to give some general principles — 
some brief indications of directions — rather than a more detailed ac- 
count of "mental hygiene" as it should be applied, a task for which 
obviously none of us would as yet be prepared. 

In another way the writer feels that the situation in regard to the 
mental abnormalities differs from other diseases, and that is, that we 
cannot presuppose an adequate knowledge of them by even the average 
physician in the same way as we do in regard to many other diseases. 
For that reason it is indispensable to give a brief account of the main 
principles, so far as we know them, which underlie each of the most 



758 MENTAL [HYGIENE 

important mental disorders and those which chiefly claim our interest 
when we think of the possibilities that may be open to preventive 
medicine. 

MENTAL DISEASE DUE TO TISSUE CHANGES. 

In doing this we must mention the fact that for our purposes we 
may divide mental disorders into two large groups: The first is one 
in which the mechanism of the diseases is easily grasped by the average 
physician who thinks in terms of diseased organs as the primary seat of 
function abnormalities. This is a group of disorders in which it is clear 
and evident that the mental changes are the directjDutcome of tissue 
changes in the brain. We will give a brief accountof^the chief ones. 

1. General Paralysis. — Anatomically this is represented by a 
diffuse inflammatory-degenerative process in the brain which depends 
on the fact that the syphilitic virus (Spirochete pallida) has invaded 
the nervous system. This knowledge that syphilis is the cause of 
general paralysis, though it is gradually becoming more widespread, 
is not yet sufficiently general. It should be as clearly appreciated as 
the fact that typhoid fever is due to contaminated water, and the 
like. Pilcz, in statistics on army officers 1 and prostitutes 2 in Austria, 
has shown that in the former about 4.75 per cent., and in the latter 
about 1.32 per cent., of those affected with syphilis succumb to this 
brain disease. It is probable that inadequate treatment of syphilis has 
something to do with the later development of general paralysis. But 
there seem to be also other factors which help, possibly factors of 
stress and strain. There is evidence to show that people who live a 
simpler life are less apt to develop general paralysis. At any rate 
Rudin 3 tells us, e. g., that in Algiers among the natives, in spite of the 
fact that syphilis is very prevalent, general paralysis is almost unknown. 
Clinically the disease manifests itself by a peculiar dilapidatio of 
behavior beginning with a deterioration in the finest mental adjust- 
ments, or as Campbell 4 expressed it, of those most complex reactions 
which are the essence of the personality. With this are often associated 
a certain elation and grandiose ideas. Soon there supervenes a grosser 
progressive deterioration of all mental operations with grave loss of 
memory. Various neurological symptoms, into which we need not enter, 
accompany the disease throughout its course. It leads to a fatal ter- 
mination, as a rule, in three or four years after the onset of the first 
symptoms. 

In order to give an idea of the relative frequency of this disease, 
we may state that according to the statistics of New York State 
more than 20 per cent, of all the male first admissions to the metro- 
politan hospitals for the insane are cases of this disease, and that 

1 Mattauschek und Pile?:: Beitragezur Lues-Paralysenfrage. Ztschr. f. d. ges. Neurol. 
und Psych. Originalien, viii, 133. 

2 Pilcz: Zur Frage der progressiven Paralyse bei den Prostituierten, etc., Jahrbucher 
f. Psych, u. Neurol., xxxvi, 65. 

3 Zur Paralysenfrage in Algier, Allgem. Ztschr. f. Psych.. 1910, Ixvii, 679. 

4 The Nature of the Dementia in Dementia Paralytica, Psychiatric Bulletin, i, p. 316. 



MENTAL DISI OVM TO CHAXGI 759 

throughout the State and among both sexes it is represented by an 
verage of 13 per cent, of the first admissions. It is also of interest to 
now, e. g. t that, as Salmon 1 has shown, the number of deaths in New 
ork State from general paralysis during 1910 amounted to half the 
umber of deaths from typhoid fever. The same writer has also 
Dinted out recently that, since most deaths from general paralysis 
3cur between f orty and sixty years of age, this disease is represented 
i 1 out of every 9 deaths of men during these two decades. The dis- 
ise breaks out as a late manifestation of syphilis ten to twenty years 
Pter the primary infection. For that reason it affects mostly persons 
l the third or fourth decade of life; now and then it is, however, also 
en in the second decade, indeed even in the first, partly as a result 
P hereditary syphilis, partly as a result of syphilis acquired in earry 
liliihood through nursing, and the like. 

_ Cerebral Syphihs. — Syphilis also gives rise to a small number 
' mental disorders which differ both anatomically and clinically 
om general paralysis. They are due either to sj^jhihtic endarter- 
is or to various meningitic involvement or gumma formations. They 
ffer clinically from general paralysis in various ways, the most 
riking of which is that they are likely to be less rapidly and less 
evitably progressive. 

The arteriosclerotic brain atrophies and senile dementias which also 
?kmg in this group we need not consider here. 

Menial Disorders Due to Alcohol.— The two types of disorders 
hich we have to consider here are the alcoholic delirium and the so- 
illed polyneiiritie or Korsakoff psychosis. The clinical symptoms of 
coholic delirium are sufficiently well known to physicians so that we 
ttd not describe them here. About the polyneuritic psychosis we 
lafl only say that this not infrequently begins like a delirium, while 
ter the initial stage the clinical picture is dominated by a peculiar 
sfeet of memory, namely, an inability to retain impressions. Asso- 
rted with it are often symptoms of a peripheral neuritis, with various 
otor paralyses. Although chronic alcoholism is the fundamental 
not directly responsible for these conditions. We probably 
ive to assume some sort of metabolism disorder which arises on the 
isis of chronic alcoholism and which in turn brings about these mental 
seases. The anatomical alterations in these alcoholic diseases have 
)t been so well worked out as, e. g., in general paralysis. Nevertheless 
ey are unmistakable and constant. 

IEVENTION" OF MENTAL DISEASES DUE TO TISSUE CHANGES. 

If we now consider what problems for preventive medicine arise in 
►nnection with this group, we see at once that there are essentially two 
iological factors which attract one's attention: syphilis and alcohol. 
When we consider the fact that syphilis gives rise directly to 14 or 

1 Two Preventable Causes of Insanity, Popular Science Monthly. Jump. 1910; Chapter 



700 MENTAL HYGIENE 

15 per cent, of all first admissions to the hospitals for the insane, this 
is in itself startling-, but in reality it does not give us the entire story 
which can be told about the influence of syphilis on mental health. It 
is., above all, necessary to speak in this connection of various studies 
on the offspring of syphilitic parents. 

I shall mention, somewhat in detail, only one study, namely, one on 
the offspring of parents with syphilitic involvement of the nervous 
system made by Hauptmann. 1 This investigator examined 43 families, 
in 35 of which both, in 8 of which one of the parents had either paresis 
or locomotor ataxia or other known syphilitic involvement of the 
nervous system, or at any rate presented a positive Wassermann 
reaction. Among these 43 families there occurred altogether 129 
pregnancies. The fate of these was as follows: Abortions, premature 
births with early death, stillbirths, or death early in life were the 
result of 57 pregnancies; 13 living children were not examined. This 
leaves 59 living children who were studied. Twenty of these had 
evidence of syphilis manifested in the following ways : 2 had hereditary 
body syphilis; 7 had either paresis or other well-known syphilitic 
involvement of the nervous system; while the remaining 11 showed 
positive Wassermann reaction without well-known syphilitic involve- 
ment of the nervous system; but among these 11 there were 3 imbeciles 
and 8 neuropathic or underdeveloped individuals. 

This leaves 39 children who presented no positive evidence of syphilis 
(i. e., no known syphilitic disorder and negative Wassermann reaction). 
Among those 39 there were: 1 epileptic, 4 with hydrocephalus, 5 
imbeciles, 12 who were either psychopathic or underdeveloped or had 
dementia precox, and only 17 children who were essentially healthy. 
Only 17 among 129 pregnancies! While especially in the cases of 
psychopathic and epileptic individuals in which we have no evidence 
of the disease being directly syphilitic, the relation with syphilis is not 
clear, and.w T hile it must be admitted that direct psychopathic heredity 
may have played a role, the possibility also exists that syphilis may 
be responsible by having brought about some vitiation of the vgerm 
plasm. 

W T hen we take all these facts together, it is obvious what a serious 
indictment the experience of the psychiatrist adds when we consider 
the ravages of syphilis and how much impetus that aspect of medicine 
brings toward a concerted action against syphilitic infection. This is 
all the more indicated since even with our present methods of treatment 
we are relatively hopeless in face of by far the largest number of cases 
which have above been enumerated. The prevention of syphilis is 
treated in another chapter of this volume. Here we should mention 
only the fact that undoubtedly all efforts that bring about an- early 
and thorough treatment of syphilis will also help to lessen the mental 
disorders arising from this cause. 

Next welcome to alcohol. The influence which alcohol has in the 

1 Serologische Untersuchungen von Familien syphilogener Nervenkranker, Ztschr. 
f. d. ges. Neurol, u. Psychiat., viii, 36. 



MENTAL DISEASES DUE TO TISSUE CHANGES 761 

production of insanity is more difficult to estimate than that of syphilis. 
There are, however, as we have seen, mental disorders which are 
specifically disorders of chronic alcoholism, namely, chiefly delirium 
tremens and Korsakoff's psychosis. But here again if, in gauging the 
influence of alcohol on the mental health, we were to confine ourselves 
to these, we would have a very inadequate idea, because, in addition 
to these, alcohol is a more or less important contributing factor in 
man}- cases of otherwise constitutional mental diseases, thus producing 
especially various hallucinatory and delusional states, or even some 
forms of excitement and depression, and there is an uninterrupted series 
from those cases which are essentially due to alcohol, to those for 
which this cause is only more remotely responsible. 

There is no doubt that the serious effect of alcohol on the nervous 
system has sometimes been overstated, but in addition to the fact that 
it produces specific mental disorders, we cannot get away from the 
classical experiments of Kraepelin, who demonstrated plainly the 
paralyzing effect on the mind of even small doses of alcohol, nor from 
the experimental proof that alcohol acts on the germ plasm and leads 
to degeneracy in the offspring. In recent years, to be sure, a certain 
diminution of the essentially alcoholic psychoses has taken place in the 
New York State Hospitals which, according to Pollock, 1 has gone 
hand in hand with a diminution of manifest intemperance in the 
history of all first admissions to these hospitals, but the specific alco- 
holic psychoses still represent 8.4 per cent, of all first admissions in 
men, while intemperance was found in 28.2 per cent, of all first male 
admissions. While then, as I have said, the influence of alcohol in the 
production of mental abnormality may have been overstated at times, 
this makes really very little difference, because there remains much 
harm that must be laid at the door of alcohol which is responsible for 
so much disturbance of mental balance in one way or another, mani- 
festing itself in either misconduct, crime, inefficiency, or insanity, all 
of which bring untold misery to many innocent families. Even with a 
conservative attitude we must admit, therefore, that, as in the case of 
syphilis, psychiatric experience brings to the campaign against alcohol 
impressive facts. This is, of course, not the place to deal with the 
many ways in which temperance may be fostered. But one fact should 
be specially insisted upon in this connection. * We know that immoder- 
ate drinking is often a symptom of a psychopathic condition and that 
by proper painstaking study it may be possible to determine the real 
forces at work which push the patient into his destructive habits, a fact 
which is of importance in considering what individual treatment may 
do in preventing alcoholic mental disorders. When this is impossible 
there is essentially one other means of managing these cases, namely, 
the formation of societies for total abstinence, because it is often too 
difficult for an individual to overcome a deep-seated habit without the 
help of a group in which the example and the whole spirit of the group 
carries him along. 

1 Decline of Alcohol as a Cause of Insanity, Psychiatric Bulletin, ii, 103. 



762 MENTAL HYGIENE 

MENTAL DISEASES WHICH ARE CONSTITUTIONAL. 

The disorders of the second large group are less clearly understood in 
their nature. It comprises, to mention only the most common forms, 
all those cases which have been provisionally grouped under the head 
of dementia precox and manic-depressive insanity, and the many cases 
of so-called psychoneuroses and psychopathic personalities which are 
often not regarded as insanity, yet which nevertheless suffer from 
mental abnormalities. We may at once state that the various dis- 
orders which are here grouped together may properly be regarded as 
constitutional disorders for reasons which will presently appear. Now 
one striking feature about these consitutional disorders is that they are 
not so clearly demarcated as those of the first group, and the con- 
scientious investigator must constantly admit that, much as this may 
be in opposition to his desire for simplicity and for smooth classification 
constant transition forms are encountered, partly between the different 
psychoses, partly between these and the psychoneuroses and psycho- 
pathic personalities. 

When we took up the diseases of the first group, we were able to 
start with a description of the physical basis of the various disorders, 
i. e., the anatomical alterations in the brain which we had every 
reason to assume to be the fundamental changes; and we could point 
to the syphilitic virus, chronic alcoholism and to disorders of metab- 
olism produced by the latter. In the disorders of which we are now 
speaking, we know very little about external causes or changes in 
metabolism, while anatomical changes have been demonstrated in one 
group, namely, in certain cases of dementia precox, but for the present 
we must admit that their relationship to the mental changes is not so 
clear, nor are they so constant as those in the first group. On the other 
hand, in contradistinction to the first group, we find that a psycho- 
pathic heredity is much more common and, above all, that we see in 
all these cases a marked tendency for constitutional mental abnormal- 
ities to exist more or less throughout the lives of the individuals. It 
is for this reason that the term constitutional disorders seems appro- 
priate. The mental collapse, therefore, grows, as it were, out of the 
personality. These abnormal traits of personality are likely to be 
inherited, yet not in the same sense as, e. g., the color of our eyes or 
the shape of our noses is inherited, but in the sense that they represent 
tendencies which undoubtedly can be modified for better or for worse by 
the influences of the environment. Hence, when we come to the prob- 
lem of preventive medicine, we shall have to lay stress: (1) on the 
question of heredity; (2) on the fact that, looked at from one point of 
view, we have to regard these disorders as the result of an accumulation 
of bad mental habits which finally lead to a break of compensation, if 
we may be permitted to use this term in this connection. This, of 
course, does not mean that there is not a large field for further investi- 
gation in these disorders which searches for physical abnormalities 
associated with them; and for investigation into the relation which 



MENTAL DISEASES WHICH ARE CONSTITUTIONAL 763 

these bear to bad mental habits and to the final breakdown. Indeed 
we can hardly conceive of any but a physical basis for the underlying 
constitutional abnormalities. It is, moreover, not excluded that in 
the dim future we shall be able to find a physical short-cut for improv- 
ing these constitutional tendencies, but for the present it would be 
unwise to close our eyes to the fact that our knowledge in this 
direction is as yet very inadequate but that, on the other hand, we 
have at our disposal certain means of mental training and of the 
teaching of proper mental habits which, in cases who are constitution- 
ally not too heavily burdened, w T ill do more or less to safeguard the 
individual against mental breakdowns. That there are others who, by 
the intensity of their constitutional bent, are almost inevitably doomed 
to final wreckage should not discourage us in our endeavors. At any 
rate, this seems to the writer a more conservative and at the same time 
a practically more useful attitude than the constant attempt which is 
made without adequate foundation to regard dementia precox and 
manic-depressive insanity from exactly the same point of view as, e. g., 
general paralysis, and to wait with any attempt at prevention until we 
have a full knowledge of the evidently very complex mechanism of 
these disorders. To state it once more, therefore, the fact that the 
conditions here included are called constitutional and are opposed 
to the more specifically organic ones of the first group is not due to a 
neglect of the yet vaguely known physical or organic factors which 
may accompany these diseases, but to the fact that in addition to other 
common traits, they arise preeminently on a constitutional basis 
which fact may offer some means of attack. 

We will now briefly discuss the most important disorders of this 
group. 

Dementia Precox. — This is a disorder which occurs in individuals 
who for years or most of their lives have show T n certain personal 
peculiarities. Perhaps the most frequent type is characterized by a 
tendency of these persons to keep by themselves, not to participate 
in the pleasures, cares and pursuits of those about them. They are 
likely to meet difficulties by shirking or going off by themselves. As 
children they do not play freely with others; they do not make friends 
easily and later have difficulty in getting into natural contact with the 
opposite sex. They are apt to be sensitive and stubborn. Sometimes 
they are so-called goody-goody children, with excellent school records, 
bookish and interested in "deep subjects;" in general, they seem to 
get more satisfaction in thought than in practical activities, which 
later make more demands on one's capacity for adaptation. There are 
other types, such as the persons who never develop real interests in 
life but who are fickle, flimsy and without real aim; as children they 
are often truant. Or there are individuals who are merely dull, lazy and 
ambit ionless. Again we find a type to which belong individuals who 
are delicate, nervous, with a tendency, even as children, to hypo- 
chondriacal complaints, to frequent headaches and indigestion, given to 
fads and fancies about eating, often selfish and wilful. Few cases of 



704 MENTAL HYGIENE 

dementia precox have not. had some had mental habits. On the other 
hand, it would he very wrong' to think that such traits as above 
described invariably lead to dementia precox. 

The breakdown is apt to occur between the ages of fifteen and 
thirty, sometimes earlier, sometimes later. The clinical picture is char- 
acterized essentially by an estrangement from the environment with 
the development of various abnormal ideas in the form of hallucina- 
tions and delusions; or by peculiar mental attitudes and the breaking 
through of various more automatic mental mechanisms which give 
the clinical picture its bizarre appearance. It is likely to lead to a per- 
manent defect, not at all characterized by an interference with memory 
but with more or less pronounced permanent lack of normal responsive- 
ness to the environment. In order to give an idea of the frequency 
of this disorder, I may say that according to the statistics of the New 
York State Hospitals for the Insane over 23 per cent, of the first 
admissions belong in the general group of dementia precox, and that 
in 1915 over half of the 36,663 patients in these hospitals suffered from 
disorders thus classified. 

Manic-depressive Insanity. — This is a much less formidable disorder, 
as it does not lead to a permanent defect, though it often appears in 
recurrent and sometimes frequent attacks. Here, too, we are likely to 
find that the patients before the breakdown showed certain abnormal- 
ities of the personality, more particularly a tendency to marked mood 
changes or to habitual abnormal moods. The symptom picture may be 
described as usually dominated by signs which bear a decided resemb- 
lance, though in a markedly exaggerated form, to normal emotional 
reactions, particularly elations (mania) or depressions (melancholia). 
An idea of the frequency may be gained from the fact that according 
to the New York Statistics of 1915 over 15 per cent, of the first admis- 
sions to the hospitals for the insane belonged to this disorder. 

Psychoneuroses. — The so-called psychoneuroses comprise a very large 
class. Here should be mentioned hysteria, wdiich imitates a great many 
physical diseases, from mild abnormalities to various motor paralyses, 
spasms, blindness, inability to speak, and even febrile states. It also 
may give rise to peculiar states of mental clouding. Then there are 
other psychoneuroses characterized by compulsion to do certain acts or 
to think certain thoughts against the better insight of the patient who 
feels toward these phenomena as toward something which is foreign to 
his thinking and acting. Patients should also be spoken of who have 
absurd fears about touching objects, about crossing the street, being in 
a closed place, going on a railroad train, and the like. There are also 
the irresistable impulses to steal or do other acts which are not suffi- 
ciently explained by conscious reasons. Other states might be men- 
tioned. We will only add that often the habit of alcoholism has a 
similar neurotic basis. There are also peculiar aberrations of personality 
such as certain types to which we have already called attention in our 
description of psychoses. To these we may add a few others, such as 
the phantastic persons who may be pathologically untruthful, those 



MENTAL DISEASES WHICH ARE CONSTITUTIONAL 765 

with undue suggestibility the intensely irrascible, and the anti-social 
individuals which include certain of the habitual criminals, and finally 
the various forms of consitutional aberration of the sexual instinct. 
^Yhenever these neuroses and peculiarities of personality are marked 
enough, even the layman recognizes in them distinct deviations from 
the normal, but there are many cases which are closer to the normal 
and which also should attract our attention. It is of these especially 
that we shall have to speak again later on, when we shall call attention 
to the fact that it is important to recognize health questions in them. 

The Increase of Insanity. — In dealing now with the problem of preven- 
tive medicine in connection with the constitutional disorders, it may not 
be out of place to say a few words about the alleged increase in insanity. 
Although it is difficult to settle the question whether insanity is or is not 
on the increase, since we do not have adequate statistics of any but the 
cases in institutions, we can say at any rate that no valid proof has 
been brought forth that such an increase actually exists. Of course 
we have statistics which show a marked rise in the admissions to the 
hospitals for the insane, and we know that this rise is far in excess of 
the growth in population. Indeed, this is the experience all over the 
world. But, in the first place, the time for which this marked increase 
in the admissions to hospitals for the insane has been shown — i. e., 
the last fifty years at most — is relatively so short that it must arouse 
our suspicion at once as to the correctness of the view that all or much of 
it means an actual increase of insanity, because an actual progressive 
racial deterioration which this would imply, could not possibly come 
about so quickly in such proportions. Nor do I believe that factors in 
modern life can be made responsible for it. We are certainly not able 
to see in any of them sufficiently definite causes of insanity to an 
extent which would account for any pronounced increase. Moreover, 
the following facts also point in the same direction: Salmon 1 has 
shown that if we leave out of the reckoning the exogenous causes, like 
syphilis and alcohol, "the ratio of the insane to the population would 
actually be greater in the quiet countryside than in the cities, in spite 
of their congestion of population . . . and their increased economic 
stress." On the other hand, we know quite a number of factors which 
naturally would account for much of the rise in admissons to the 
hospitals for the msane, factors which concern essentially a changed 
attitude of the communities and individuals toward mental disorders. 
Among such factors we may mention the better provision for the care 
of the patients in the hospitals for the insane; the greater confidence 
of the public in these hospitals; the difficulties of existence, especially 
in large cities, which make it harder than formerly to take care of 
patients at home; the more general and earlier recognition of mental 
abnormalities, etc. Indeed it is the opinion of various careful investi- 
gators who have studied the situation in different countries that 
when once a certain level of provision for mental disorders is reached 

1 Two'Preventable Causes of Insanity, 1. c. 



700 MENTAL HYGIEXE 

the proportion between admissions to hospitals for the insane and 
population will be a much more stable one. 

Heredity and Eugenics. — Coming now to the specific problems in hand, 
we must, as we have already stated, give our first consideration to the 
question of heredity and eugenics. 

In spite of a certain tendency which has made itself felt of late 
years to regard the issues of psychopathic heredity as practically 
settled, owing to the discovery of Mendelian laws in regard to some 
features of plants and some simple traits or abnormalities in animals 
and man, we must insist that these questions in regard to the inheri- 
tance of mental abnormalities are still far from clear and the situation 
is undoubtedly much more complicated than would appear from some 
statements that are made with such confidence. It seems to us, there- 
fore, that instead of giving anything like general rules, for which our 
knowledge is not as yet adequate, it is perhaps best to illustrate some 
general tendencies by an example, very much as we did in the case of 
the effects of syphilis of the nervous system on the offspring. I take 
this example from an interesting and well-balanced article concerning 
these questions by Adolf Meyer. 1 

Meyer had four interrelated family groups in a school district of 
Baltimore worked up in which 522 persons were studied, among them 
children who were foimd in the schools to be defective. He makes 
three groups: The first comprised 11 matings, in which both parents 
were normal, but in 4 of these matings both parents showed by their 
family history that their stock was tainted. The result of these was 
that one of the offspring was defective, and 3 to 6 were normal; while 
in the other 7 matings, in which but one parent was tainted, "the 
results were correspondingly better." The second group comprised 
9 matings, in which one parent was defective. In the cases in which 
the defective was married to a normal but tainted individual, the 
progeniture contained about an equal number of defectives and normals ; 
whereas among the defectives who married normals that were not 
tamted, there were 2 defectives, 6 uncertain, and 15 normal children. 
A third group comprised 4 matings, hi which both parents were defec- 
tives. The result was 21 defectives, 1 sex offender, 4 uncertain, and 
only 1 normal. 

Meyer justly states that what holds for mental defectives, in 
the sense of imbecility or epilepsy, holds also for mental diseases, 
by which undoubtedly he means the mental disorders of which we 
have spoken above as constitutional, but that in this it is fortunately 
not the inheritance of an actual condition with which we are dealing, 
but rather an inheritance of a disposition to abnormality. 

The lesson of such a group, even if we do not attempt to claim any 
hard and fast rules or laws from it, is obvious. Matings in which both 
parents are clearly abnormal, in one case insane or markedly psycho* 

1 The Right to Marry, The Survey, June 3, 1916. 



MENTAL DISEASES WHICH ARE CONSTITUTIONAL 767 

pathic, are to be avoided, and the public should be impressed with 
the fact that even the mating between such individuals and persons 
markedly tainted, involves considerable danger, whereas the mating 
of a tainted or psychopathic individual with a member from a normal 
stock, involves correspondingly less danger. The somewhat crude 
idea of legislation, partly in the form of sterilization or prohibition of 
marriage, should be regarded with suspicion, except in the most 
glaring cases. In the first place, we must not overlook the fact that 
in every case in which such legislation has been passed, no adequate 
provisions were made or, for that matter, could be made for carrying it 
out, for we must admit that our knowledge on which to base the 
execution of such laws is not sufficient. This is especially the case as 
regards the question of determining the importance and significance 
of various degrees of abnormality. In the second place, we must never 
forget that psychopathic tendencies, when they have been properly 
managed, have, after all, furnished much in our civilization that is of 
distinct value, and that we would not like to miss. We only would 
have to imagine what would happen to progress, more particularly in 
the way of altruistic or artistic endeavors, if all psychopathic traits 
were left out, to appreciate what a wholesale stamping out of these 
traits would mean. After all, we cannot and should not try to settle 
everything by legislation, but we have, rather, to develop a better 
public conscience in regard to the great responsibility of marriage 
and parenthood. 

There is a justifiable discussion as to the relative importance of 
heredity on the one, and the importance of the influences by which the 
growing child is surrounded on the other hand; but when we come 
to deal no longer with potential but with existing individuals, it does 
not matter to which of these factors we are inclined to give more 
weight; we must, in order to accomplish anything, be one-sided, in the 
sense that we put our whole emphasis on training and environmental 
influences, and this for the present must be an insistence upon proper 
mental hygiene in the restricted sense of the term. In order to be clear 
at what hygienic mental training must aim, it is important to be fully 
impressed first with the fact that life demands constant adaptations, 
as well as adjustments, between our more individualistic, instinctive 
tendencies and the requirements of society; and secondly with the 
fact that most mal-adjustments and bad mental habits are formed 
early in life. We shall therefore lay most stress upon childhood. 

Considering the present state of our knowledge and the lack of 
organization of it, we shall, as has already been stated, not be able 
to give in the following anything but a very imperfect account of certain 
principles, and shall have to confine ourselves to hints here and there 
about some issues in regard to which the physician who studies the 
lives of his patients finds that mistakes have most often been made. 
We certainly would not claim for these remarks anything like com- 
pleteness. 



708 • MENTAL HYGIENE 

MENTAL TRAINING IN INFANCY. 

A widespread misconception is that we need not think of proper 
mental training in the infant. But what has just been stated shows 
that this cannot be begun too early. Undoubtedly the trouble often 
lies in the fact that the parents themselves are not well balanced and 
much that is laid at the door of heredity is in part the result of imitation 
of bad self-management that the child witnesses in the adults of its 
environment. It is a difficult question for the physician to settle in a 
given case, whether a child or even an infant should be removed from 
plainly psychopathic parents, and yet there is no doubt that there are 
cases in which this would be the only safe course if we could be sure 
that then we really improved the environment. But there are many, 
even neurotic, parents who can be taught and who would be willing to 
do what is right if they but had enough information. 

Even in the infant a certain regularity of habits is essential, not 
only from a physical point of view but from a mental as well, and this 
largely because it supports any attempts at training of self-control. 
The most important specific situations in which there is a demand 
for such training are those first reactions of evasion and shrinking so 
common in the infant as well as the older child, through which it tries 
to force others to yield to its impulses of the moment. It must be 
made clear, therefore, to the child that crying, tantrums, and the like, 
will not accomplish anything. This will undoubtedly often make 
considerable demands on the resourcefulness, as well as on the self- 
control of parents. Also even early in life much petting and caressing 
is very apt to prepare the child badly for life, not only because it cannot 
help but emphasize too much a certain erotic tendency, which in its 
undeveloped form is naturally present in the child, since the sexual 
instinct does not arise de novo at puberty, but also because it is opposed 
to the necessary requirement that the child must learn to adapt to a 
life of hard reality. The neurosis of the single child is too well known 
not to stand as a warning in this respect. Love for the child is best 
shown, and in the end best appreciated, in constant thoughtfulness 
for its welfare and wise guidance, and this of course need not be 
clothed in an unbending sternness. In fact too much sternness and 
harshness is quite likely to create in the child a lifelong false attitude 
which often determines, consciously or unconsciously, an antagonism 
against any authority, and since most people have to be " under" 
somebody, and since we all have to subordinate our egotistic wishes 
to the social good, it is obvious how much trouble this may and 
actually does create. It is also apt to bring about a lack of frank- 
ness which, in addition to other results, certainly tends to block all 
attempts at sensible guidance. In the same way it is essential that the 
child be not too much shielded from unpleasant sensations, but learn to 
bear pain and discomfort without constantly being treated as if this 
were something which did not belong to the ordinary run of life. Quite 



MENTAL TRAINING IN INFANCY 769 

important in this as well as in other respects is the contact with others 
on the same level as the child, i. e., with other children. They are 
often the best educators; but they may also do harm, and the choice 
of the right type is one of the important duties of the parent. Here 
we should be guided not merely by social convention, w T hich from the 
point of view of mental hygiene appear often enough silly, or by the 
pocketbook of the father, but by real character traits. 

It is often stated that it is necessary to teach the child to control his 
emotions. This is good advice in so far as those emotions are concerned 
which we might call destructive, or at any rate those which get the 
child out of contact with the environment, e.g., anger and envy. It is, 
however, not wise to make the child merely suppress such feelings; the 
reactions should be changed fundamentally. In general, a puritanical 
stamping out of the visible signs of emotion is likely to make the child 
emotionally dwarfed and unnatural. It must, moreover, not be for- 
gotten that the emotions are precisely those reactions which bring 
about the natural contact with the environment and which are there- 
fore helpful. And there are many emotional reactions which in other 
ways are thoroughly constructive in the sense that they will furnish 
in later life important sources of satisfaction and thus become balancing 
factors which greatly facilitate adaptation. The enthusiasm for the 
good and beautiful, the healthy exurberant joy in play and in success, 
for example, those we have every reason, from the point of view of 
mental hygiene, to encourage. 

The psychiatrist knows well certain dangers of day-dreaming, yet 
we must also be aware of the fact that many of the best thoughts and 
actions in the adult have their inception in that realm and only receive 
their final practical shaping by the modifying and pruning process 
exerted by a good sense of reality. Hence a certain amount of day 
dreaming, like play, is a natural function. It is necessary, therefore, 
that day-dreaming, rather than be suppressed, be supervised and held 
in check by seeing that beside it there develops a good appreciation for 
the concrete and its value and a sound respect for the truth. But we 
need not oppose a child's enjoyment of and belief in symbols, because 
after all we camiot express everything in life in scientific terms, indeed 
some of what is best and most elevating belongs in the class of these 
imponderables. There is therefore no objection to the belief in Santa 
Claus, and the like, nor to the enjoyment of good fairy tales. They, 
too, do represent truth and make life richer. 

Harm undoubtedly can also be done to the children by forcing them 
into appearing something which is beyond them. This is true not 
only in regard to pushing them in their studies beyond their capacity, 
but also in making them profess something which they do not feel. 
It should be appreciated, for example, that children have not the same 
interests which adults have, nor are their altruistic feelings developed 
to the same degree. To force them into wrong attitudes in this respect 
is certainly not likely to create a wholesome frankness. 
49 



770 MENTAL HYGIENE 

TRAINING OF OLDER CHILDREN. 

Especially in the older children we must not be deceived by so-called 
model behavior, which may be associated with shunning intercourse 
with other children or the actual doing of things with others, in place of 
which we find undue occupation with books and with subjects which are 
fit only for older periods of life. These traits, therefore, often repre- 
sent a defect rather than an advantage, no matter how much they 
may please the parents. They are doubly dangerous because they hide 
behind an exterior of apparent excellency a desire to shirk the real 
adaptation to life and are apt to throw the child back upon himself and 
foster what we might call a malignant day-dreaming that leads more 
and more away from contact with reality. It also is hardly enough 
appreciated, especially by nervous parents, that the child must have a 
certain freedom and possibility to shape his life, under proper guidance. 
Some neurotic children are only too likely to desire a certain domination, 
which must not be yielded to, and many nervous invalids suffer later 
because they never were trained to depend upon themselves. Quite 
important is it also that the child develop proper standards of conduct. 
We do not refer in this so much to moral standards, which of course are 
important but are more generally appreciated, but rather that care be 
taken not to foster false ambitions. Behind much of the sensitiveness 
that we see in children and adults there are false ambitions and false 
attitudes toward what one has a right to expect from the world, which 
require most careful investigation, explanations, and more than any- 
thing else, good examples on the part of the environment. Any one 
who has the important duty to guide a child must, above all, have 
worked with himself and have attained a certain clearness about his 
own personal attitudes and motives. In general, we must remember 
that the bringing up should be essentially a training in adaptation to 
life, with its various knocks and disappointments, as well as its fortunes 
and successes. 

A serious mistake which is often made is that people are not suffi- 
ciently impressed with abnormal traits. Many people are likely to look 
upon caprices, fads, ill-balanced desires, above all, moods, and the like, 
from the point of view that they are "just natural," or that "any child 
might have them." But one of the most important pieces of advice 
we can give is that we must appreciate that they are traits which 
should be investigated, often not without the help of a competent 
physician who is capable of studying and understanding the meaning 
of such traits. Here also should be mentioned a host of so-called 
physical symptoms, such as frequent headaches, digestive disturbances, 
bed-wetting, and the like. A neurotic tendency should always be sus- 
pected behind these, and a physician should determine whether there 
is a physical basis or whether these tendencies represent wholly or in 
part psychopathic traits, and should therefore be objects of mental 
treatment, 



; 



MENTAL TRAINING AT PUBERTY 111 



THE SCHOOL AND MENTAL HYGIENE. 

A word should be said about the school. If the essential of the 
education is character formation, not only from its moral but also 
from its hygienic aspect, it is obviously one-sided that the school still 
lays stress only on the acquisition of knowledge. It is surely not the 
wish of psychiatrists to neglect this, but the school too should recognize 
— and I do not hesitate to repeat this at the danger of becoming monot- 
onous — that the chief task of life is adaptation and that whoever has a 
hand in the shaping of the child's mind and mental habits should recog- 
nize that this must not be neglected. This can, perhaps, hardly be 
included in a curriculum of the school; but it must be expressed in the 
spirit of the teacher and the school in general and should be supported 
by well-trained school physicians and clinics in connection with the 
schools. It will be a long time before such tendencies will have an 
adequate footing in our schools, and yet if we but followed the teach- 
ings of Pestalozzi and the most enlightened educators, and supple- 
mented this, as I have said, by capable physicians trained in the study 
of mental abnormalities, so that, when slight danger signals arise, they 
would be the objects of investigation and treatment rather than punish- 
ment or neglect, much would be accomplished. A school should be 
judged not only by the examination records but also by the kind of 
individuals it turns out. 



MENTAL TRAINING AT PUBERTY. 

Puberty is the period in which essentially two features enter into 
the life of the growing human being — the beginning of the loosening 
of home ties and the sexual longings. The purpose of these is prepara- 
tion for stepping out into life as a self-reliant being, and for the fulfilling 
of the biological demand for the propagation of the race which is 
connected with the sexual instinct and accomplished by the looking 
for and the finding of a mate. How often do we pay attention to the 
struggles which are associated with these important demands for 
adaptation! That the period runs smoothly enough in many normal 
individuals is true; on the other band we also know that it is the most 
important period at which the manifestations of neuroses or psychoses 
begin first to show themselves. We should recognize a natural desire 
for some freedom from home ties in the boy or girl approaching adoles- 
cence, rather than through selfish motives keep them dependent, as is 
too often the case by well-meaning but morbidly anxious or poorly 
informed parents. That this does not mean an abandoning of the 
growing child to its own devices and unbridled longings, I hope is 
sufficiently emphasized by the general spirit of this chapter. 

Then as to the sexual instinct. There is no doubt that, among those 
who advise the child, more frankness should exist and more of a sensible, 
sympathetic attitude, so that the desire for advice, present often 
enough, but, since it concerns such personal matters, so easily thwarted, 



772 MENTAL HYGIENE 

is encouraged rather than repelled. Every psychiatrist who has care- 
fully studied the lives of his patients knows how rarely such a desire 
is encouraged, partly through thoughtlessness and lack of appreciation 
of the real difficulties, partly because these matters have never been 
properly dealt with by the would-be advisers themselves. 

This naturally leads to the question of masturbation. My exper- 
ience as physician has been that masturbation is usually treated with 
too much horror and too much mystery. It must not be forgotten 
that a certain amount of masturbation is very common and often does 
no harm; and it is not correct to say that masturbation causes insanity. 
The habit is often a symptom of a mental make-up characterized by 
seclusiveness, and out of this a mental breakdown not infrequently 
develops. For the rest, excessive masturbation is likely to bring about 
certain nervous conditions, but most often the greatest harm comes 
from the fact that the boys or girls have been scared into believing 
that by yielding to their auto-erotic impulses they have made outcasts 
of themselves or injured themselves for life. This naturally is not 
conducive to a development of a good contact with the outside world 
which is so essential. Here as in all that concerns the sexual instinct, 
a pure and open attitude which leads to explanations and warnings on 
the basis of what is decent, dignified and healthy, is most important. 
It is hard to tell which is worse, a frivolous attitude or one of horrified 
condemnation. I dare say both are equally bad and equally far 
removed from a natural way of dealing with the situation. I should 
not advocate sex instruction in school. These are matters which are 
best left to the parents or whoever has a more personal charge of the 
child or to the family physician, and we should be guided by the initia- 
tive of the child. This, however, can be done only if the spirit of 
openness above alluded to has been thoroughly developed. 

MENTAL HYGIENE IN THE ADULT. 

In regard to the general mental hygiene of the adult the most 
important advice here again seems to the writer to be that every one 
should develop a more alert attitude toward abnormal traits, not 
only educators and parents in regard to the children, but even 7 one in 
regard to himself. It has sometimes been stated that psychiatrists are 
apt to see too much abnormality. This is, of course, an absurdity. 
But psychiatrists are convinced that much would be improved if people, 
once for all, would get a clear appreciation that many traits are ab- 
normal, or at any rate require handling, such as unfounded suspicions 
or anxieties, ill-balanced enthusiasms, sudden mood changes without 
adequate reason, uncalled-for feelings of being at a disadvantage, 
feelings of inferiority, morbid indecision, tendency to too ready despair, 
peculiar warped mental attitudes, a lack of desire for natural inter- 
course with fellowmen, and many more. The public should also 
know that not only the more glaring hysterical ailments which simulate 
physical diseases but also many milder symptoms, such as headaches, 



MENTAL HYGIENE IN THE ADULT 11?> 

digestive disorders, various pains, etc., may have a purely psycho- 
pathic and not a physical basis, and that they, like the rest of the 
symptoms above enumerated, represent signals of danger of a breaking 
down of mental balance. It is, of course, not meant that all such signs 
denote that a person will become insane. We know that this is not the 
case, since these traits often represent merely a temporary disorder 
under a special stress, or a condition which, with ups and downs, 
never leads to any graver disorder, but even if it does not bring about 
more serious results, we should remember how much energy is expended 
in the struggles of such people and is taken from useful activities, 
how much trouble such traits make in the world and what hardships 
they may impose on others. Even in physical hygiene the public 
mind is not sufficiently instructed, and we are far from being con- 
vinced that health is a duty as much as moral conduct. Indeed 
health is the most fundamental ethical duty. A well-known leader in 
American medicine once said that public health would be greatly 
improved if everybody had the feeling of responsibility toward health 
which the best informed physicians have. This is precisely what I 
wish to apply to our problems of mental health. Maeterlinck in his 
"Wisdom and Destiny" has fully appreciated that we are for the most 
part responsible for what happens to us, i. e., for our destiny, and with 
wonderful insight has written much that is excellent mental hygiene 
and which should be widely read. Every physician should, therefore, 
be acquainted with the danger signals of breaking down mental balance, 
indeed every one should make it a business to train himself to a greater 
keenness in appreciating neurotic tendencies, wrong mental habits, 
unhealthy attitudes, etc. Now it is undoubtedly true that, in order 
to be able to be clear about one's own motives, knowledge is required, 
more particularly knowledge of the deeper forces which actuate us, 
for many of our real motives are hidden from us. The modern psycho- 
analytic teaching undoubtedly furnishes us with knowledge of these 
hidden forces and gives much important information. Anything which 
helps toward a formulation of our motives is valuable, even if this 
formulation is only partly correct, because this helps us to manage 
them. But if, as is natural in a new science, there is a certain one- 
sidedness, and there are many formulations which in their present form 
are not broad enough, the writer nevertheless feels that, approached 
with an open mind and looked upon as a matter which is still tentative, 
a study of psychoanalysis can be useful only if the person who occupies 
himself with it is wise enough not to be taken in too much, either in a 
positive sense of being too much swayed by one-sided conclusions, or 
in the negative sense of being repelled by certain features so that he 
turns his back on the whole teaching. But without that, much more 
can be accomplished, even with more conscious motives, than is com- 
monly done if every one had the conviction that we are, to a certain 
extent, responsible for our neurotic symptoms as illustrated above. 
The scientific determinism of the will has its place in philosophy; the 
practical man will say to himself that there is plenty of self-determi- 



774 MENTAL HYGIENE 

nation which he has no right to shirk, and that there is a healthy habit 
of working with oneself, which must not be confounded with a morbid 
introspection which, because it fusses about non-essentials and matters 
which do not go to the root, is unproductive and works harm. And if a 
person is incapable of handling the situation himself he should appre- 
ciate that he is dealing with a health question quite in the same way as 
in the case of any physical ailment in which a properly qualified 
physician should be consulted. A more widespread appreciation of 
how much is really psychopathic is likely to create also a better and 
franker attitude about such matters and do away with the absurd 
horror of all that savors of the mentally abnormal and which undoubt- 
edly is responsible for the dangerous lack of honesty in this respect. 

It is also important to remember the fact that in order to keep up 
our mental balance w r e need a certain amount of satisfaction, just as 
we need food in order to keep up our body. This is an important 
consideration for the shaping of one's life. In this respect we must 
constantly keep in mind that we have to arrange our activities so that 
they harmonize with our capacity. This may require a reshaping of 
our ambitions and a straightening out of false attitudes. Every 
psychiatrist knows how much that is neurotic arises from suchj/alse 
attitudes and that they cannot be changed in a day. One of the most 
stable satisfactions is derived from a duty well done, and w T e are all 
surrounded with such duties, be it in our chosen work, or in needs 
which surround us and which call for service. Putnam says very 
justly that the more fully a person tries to give expression to his whole 
self (obviously a great health problem) the more fully he lives outside 
of himself. Work is certainly one of the greatest blessings that human- 
ity has, and to train one's self to satisfaction in even simple but concrete 
accomplishments is undoubtedly an important rule of mental health. 

But here should also be mentioned all those balancing factors which 
come to us from intellectual pleasures, sensible hobbies, and above all 
esthetic pursuits, such as music and art in general. The richer we can 
make life in stable satisfaction, the more we shall be able to weather 
difficult situations. It is important to grasp fully the value of such 
balancing factors and the necessity of a certain multiplicity of them, 
so that w T e do not have all the eggs in one basket. This is especially 
true in women who often have a life that is less rich than that of men. 
How many a mother has seriously broken down over a death or other 
change in her family because her life was too narrow. It is also a 
matter which may well be remembered by men who give up their 
occupations in later years. If the latter constituted the essential 
satisfaction upon which they lived, they cannot expect to retain their 
nervous balance when they are suddenly deprived of it. 

THE MARITAL STATE AND MENTAL HYGIENE. 

We should not omit mentioning the great demands upon adaptation 
which married life makes. To make ourselves appreciate fully the 



GENERAL MEASURES IN MENTAL HYGIENE 775 

importance of this subject, we have only to remember the large amount 
of disharmony which exists in this situation and the fact known only 
too well to the psychiatrist that many persons break down with 
neuroses or psychoses under the strain because it is not properly man- 
aged. Some persons undoubtedly are not fit to marry, and here a 
word should be said about the advice to marty, which is so often given 
even by physicians to neurotic individuals. The idea behind it seems 
to be that marriage creates a sexual outlet and furnishes many other 
satisfactions by giving a content to life which did not exist before. The 
latter is undoubtedly true if the person is adequately prepared for it. 
As to the sexual outlet it must not be forgotten that the sexual instinct 
is not a simple matter like hunger, a satisfaction of which is healthy 
in moderate degree, and unhealthy in excess, but it is an instinct 
which is involved in our whole development and therefore extremely 
complex. And yet general rules about who should and who should not 
marry cannot be given and every case should be decided on its own 
merits. But it must also be clearly understood that the widespread 
disharmony in married life is neurotic and not necessary. Here, above 
all, it is important not to muddle along, but to attempt to get clearness 
about the direction in which one is going and the motives which 
actuate one. There are, of course, cases where divorce may be the 
only salvation, very often much can be done by a thorough appreciation 
that both partners are dealing with a demand for adaptation created 
by the fact that they live in close contact with another personality 
w T hich has its own inclinations and its own will, and that subordination 
of many wishes is therefore required. Sometimes a competent psy- 
chiatrist must be consulted, for it is just as well to understand that such 
a disharmony is a health problem which may be too difficult to manage 
alone. 

GENERAL MEASURES IN MENTAL HYGIENE. 

There are some general measures which should not be forgotten 
in this brief account of what mental hygiene, even at this imperfect 
stage, should aim at. In the first place, it is quite obvious that those 
who should be most concerned with this as well as all other health 
problems, are the physicians. If they have woefully failed in this 
task, however, not much blame can fall upon them, so long as the 
medical schools neglect this branch of medicine almost entirely. There 
are, to be sure, some family physicians who are natural born practical 
psychologists and have enough conviction not to yield to prevalent 
medical habits; they do not forget that a human being may have 
internal struggles and tribulations and that much impairment of 
health and much "nervousness" can be removed only by entering into 
these and by modifying the patient's life. But the average physician 
shuts his eyes to all that is mental and regards everything as physical. 
This would have a certain justification if we had a full knowledge of the 
physical defects which underlie difficulties of adaptation and could 
handle them from that point of view. This is obviously not the case, 



770 MENTAL HYGIENE 

and even it' we knew much more than we do there would still be the 
had mental habits which, after thorough investigation of their nature, 
demand retraining on the basis of this knowledge. The result is that 
the entire field has passed from the physician into other hands and 
has led to wholesale would-be management on the basis of fads. This 
will never improve until, as we have said, psychiatry has become an 
important part of medical education and until those who teach psy- 
chiatry have better facilities for teaching than are now generally 
available. It is not the men who deal with the insane only who should 
teach psychiatry, but men who have opportunities in psychiatric 
clinics in which insane cases, as well as milder mental abnormalities, 
i. e., every conceivable form of "nervousness" or abnormal conduct, 
are treated both in the clinic and in adjoining dispensaries and in 
which the guiding spirit can be made the dealing with mental abnormal- 
ities in this wider aspect of a public health problem. We are at present 
witnessing in the public at large an awakening of the recognition that 
mental abnormalities do represent an important public health problem, 
yet for the very reason that the facilities above mentioned are not 
available we constantly find that we have in reality not enough phy- 
sicians who can adequately handle the problems. 

THE ROLE OF DISPENSARIES IN MENTAL HYGIENE. 

In regard to other public duties in this connection I may say that 
undoubtedly the increasing attention to bodily hygiene and the 
gradual improvement in the standard of living will help in preventing 
mental disorders. But we must also keep in mind more specific duties, 
and, since intelligence and education are required to accomplish 
anything in personal mental hygiene, we should mention here some 
measures qualified to help the more uneducated classes. Dispensaries 
for mental abnormalities, even the relatively few that exist, are at 
present still visited too much by persons who in reality come too late 
because they are too far advanced; but such dispensaries have undoubt- 
edly an important future as places in which the poor people who have 
"nervous" troubles should be able to obtain advice. Since any 
advice may be futile without efficient help to the patient in reconstruct- 
ing his life, such places will always fail in their function, however, 
unless they have associated with them a competent social service 
department. And there is no doubt that we shall some time see the 
advent of public sanatoria for "nervous" cases, i. e., for cases whose 
trouble, though made of the same stuff as insanity, need not have 
applied to them that legal term and who are still in a stage when a 
more serious breakdown can be avoided. In this connection should 
also be mentioned a valuable suggestion made by Adolf Meyer. 1 He 
makes the point that we are much in need of better standards in com- 

1 Where Should We Attack the Problem of Prevention of Mental Defect and Mental 
Diseases? No. 53, Reprints of Addresses of the National Conference of Charities and 
Correction, 1915 Meeting at Baltimore. 



THE TREATMENT OF THE INSANE 777 

inon ideals of solidarity and urges the formation of groups or districts 
arising out of the combining of various community activities in which 
mental hygiene should then also have its part, a suggestion which, if 
carried out in the manner which he details in his paper, would undoubt- 
edly be as valuable as it would be practical if the necessary spirit can 
be created. 

THE TREATMENT OF THE INSANE. 

But we also need better provisions for the treatment of the insane 
themselves. The surveys of the National Committee for Mental 
Hygiene have revealed that often our treatment is still not even 
uniformly humane, to say nothing of up to date. Let any one read 
Salmon's "The Insane in a County Poor Farm" to feel the whole 
shame of what is still done in some parts of this country. Indeed even 
in the States which have the best provisions there is room for further 
improvement, which would make more rapid progress if only a wide- 
spread sense of public responsibility would take the place of politics. 
The great cost of the provisions for the insane could undoubtedly be 
lowered by a systematic development of industries in which many of 
the chronic patients could take part unquestionably to their own 
benefit. Among the inadequate provisions for the insane a very 
important part is the dealing with patients before they enter the hos- 
pitals. In the first place, our very system of commitment in its various 
forms is based on a wrong conception. There will undoubtedly be a 
time when people will look back, as to a barbarity, to the fact that 
legal proceedings had at one time to be gone through to get a sick man 
into a hospital for treatment, and now that it exists it undoubtedly 
adds to the horror of the situation. The matter could be handled 
much better in a medical spirit. Even now there exist ample pro- 
visions for appeal to courts and for official supervision of detention, 
so that it is unnecessary to burden every one who has the misfortune 
to have a mental breakdown with a legal or police encumbrance. 
Then, again, how many communities have adequate provisions so that 
a person with a mental breakdown can at once humanely be dealt 
with, instead of being taken to prisons and lockups? Here the measures 
advocated by William L. Russel of having the health officers look 
after this part and his recommendation that each community should 
make satisfactory hospital provisions for such cases are the only 
solution if properly carried out. In this respect general hospitals 
could do a great deal by having wards for mental cases. It is interesting 
that formerly this used to be the case, and there is no doubt that the 
custom will return in the form of wards for first treatment or for mild 
cases. 

Crimes and misdemeanors may often be the result of mental abnor- 
malities. It is therefore natural that persons arrested or imprisoned 
may be objects much more for treatment by a physician than for hand- 
ling by prison authorities. The gradual transformation of prisons 
into treatment stations will naturally have to be a matter of slow 



778 MENTAL HYGIENE 

•And safe development, hut even aside from this general problem 
abnormal conduct which conflicts with the law may often be plainly 
the result of a well-known mental abnormality, for the discovery of 
which provisions should be made. It is therefore a distinct advance 
in mental hygiene that a beginning has been made to have adequately 
trained psychiatrists available for consultation in prisons, juvenile 
courts, reformatories, and in connection with police headquarters. 
There is no doubt that in these various fields we have been and still 
arc guilty of much mismanagement. 

THE ROLE OF IMMIGRATION IN MENTAL HYGIENE. 

In a country like America with, in normal times, a constant influx 
of an alien population w<ho will be the future citizens, it is natural 
that immigration represents a great problem of national mental health. 
Therefore this should not be omitted in our present considerations. 
In dealing briefly w T ith this question I cannot do better than follow 
Salmon, 1 who has made a more thorough study of the subject than 
any one else. He says that it can be "earnestly asserted, after long 
study of this question, that no measures for the control of mental 
diseases and mental deficiency w 7 hich have yet been suggested can 
prove so efficacious as artificial selection of additions to our population 
on the vast scale which an adequate mental examination of immigrants 
would permit. This is a measure of practical eugenics which can be 
applied successfully now T and one in which we shall not have to wait a 
generation to note the effect. " Surely if this could be thoroughly 
appreciated by every one who has at heart the question of our national 
mental health — and what thinking American does not — the country 
certainly would embark much more determinately on this absolutely 
legitimate process of adequately selecting "the parents of future 
generations of Americans." 

REFERENCES. 

Abbot, E. Stanley: Preventable Forms of Mental Disease and How to Prevent 
Them, Boston Med. and Surg. Jour., April 20, 1916. 

Barker, Lewellyn F. : Principles of Mental Hygiene Applied to the Management of 
Children Predisposed to Nervousness. Address before the Public Health Conference 
of the Medical and Chirurgical Faculty of Maryland. Published by The National 
Committee for Mental Hygiene, No. 2. 

Campbell, C. Macfie: The Responsibilities of the Universities in Promoting Mental 
Hygiene. Proceedings of the Mental Hygiene Conference and Exhibit at the College 
of the City of New York, November, 1912. The Relation of Social and Economic 
Factors to Mental Hygiene, Am. Jour. Pub. Health, Boston, No. 12, vol. vi. 

Clark, L. Pierce: Psychopathic Children, New York Medical Journal, April 11, 1914. 

Copp, Owen: The Psychiatric Needs of a Large Community, Am. Jour, of Insanity, 
July, 1916. 

Hoch, August: The Manageable Causes of Insanity, State Hosp. Bull., new series, 
September, 1909, vol. ii; Early Manifestations of Mental Disorders, Proceedings of the 
Mental Hygiene Conference and Exhibit at the College of the City of New York, Novem- 
ber, 1912. 

1 Insanity and the Immigration Law, New York State Hospitals Bulletin, November, 
19fl; also Mental Hygiene, 1. c. 



THE ROLE OF IMMIGRATION IN MENTAL HYGIENE 779 

Hoche, A.: Geisteskrankheit und Kultur, Speyer und Kaerner Universitatsbuch- 
handlung, Freiburg i. B. and Leipzig, 1910. 

Maeterlinck, Maurice: Wisdom and Destiny, Dodd, Mead & Co., 1898. 

Meyer, Adolf : AVhat do Histories of Cases of Insanity Teach Us Concerning Preven- 
tive Mental Hygiene During the Years of School Life? Psychological Clinic, No. 4, vol. ii. 
Where Should We Attack the Problem of the Prevention of Mental Defect and Mental 
Disease? No. 53, Reprints of Reports and Addresses of the National Conference of 
Charities and Correction, 1915 Meeting at Baltimore; Organizing the Community for the 
Protection of Its Mental Life, The Survey, September 18, 1915. 

Meyer, Adolf: What can a Democratic Civilization do about Heredity and Child 
Welfare, The Survey, June 3, 1916. 

Oppenheim, H. : Nervenleiden und Erziehung, Berlin, 1899. 

Paton, Stewart: The World's Most Important Conservation Problem, Popular 
Science Monthly, August, 1912. 

Russell, William L. : The Care and Commitment of Insane Persons by Health 
Officers, Medical Record, January 22, 1910; The Prevention of Insanity, New York 
State Hospitals Bulletin, November, 1912. 

Salmon, Thomas W. : Two Preventable Causes of Insanity, Popular Science Monthly, 
June, 1910; The Insane in a County Poor Farm, Mental Hygiene, January, 1917; 
Chapter on Mental Hygiene in Rosenau's Preventive Medicine and Hygiene, Appleton 
& Co., N. Y. 

Solomon, H. C: What Shall be the Attitude of the Public Toward the Recovered 
Insane Patient? Boston Med. and Surg. Jour., April 13, 1916. 

Wells, F. Lyman: Mental Adaptation, Mental Hygiene, January, 1917. 

White, William A.: The Meaning of the Mental Hygiene Movement, Boston Med. 
and Surg. Jour., August 24, 1916. 

Williams, Frankwood E.: Psychopathic Hospitals and Prophylaxis, Boston Med. 
and Surg. Jour., June 24, 1915. 



CHAPTER XXIX. 

MENTAL DEFECTIVES. PREVENTING AND 
( CONTROLLING MEASURES. 

By HENRY H. GODDARD, Ph.D. 

The recognition and understanding of mental defectives is among 
the very important problems that confront the health officer. It is 
now generally agreed that upward of 2 per cent, of juveniles are so 
defective mentally as to be incapable of self-support and self-direction 
and are largely irresponsible. 

Because of their lack of self-control mental defectives are a menace 
to society and unless recognized and cared for they go from bad to 
worse, swelling the ranks of the drunkards, prostitutes, criminals and 
ne'er-do-wells. A still greater percentage are defective to a milder degree, 
but sufficiently so to cause them to fall into delinquencies of various 
kinds, thus often rendering them perplexing problems to those who do 
not recognize their condition. 

"Whoever will take the trouble to understand and learn to recognize 
the high grade mental defective will find himself master of many a 
problem that has proved baffling to those who have not this knowledge. 
There are thousands of cases of unrecognized feeble-mindedness com- 
plicating our social and industrial problems. 

The high grade defective or moron is the most troublesome, partly 
because he is not easily recognized as defective and partly because he 
has sufficient mentality to go about by himself and get into all kinds 
of mischief either on his own account or led on by someone else. The 
mischief of his own originating is usually very simple action though 
it may have serious consequences. He may steal but cannot plan a 
robbery. He may lie but not consistently. He will follow his impulses, 
and this will often result in the destruction of property. He may set 
fire and sometimes become a regular " fire-bug." Under the direction 
of an intelligent criminal he may execute a robbery or commit murder; 
under the direction of a good citizen the same defective may be a 
useful worker to the limit of his mentality, and a pleasant, agreeable 
and harmless person, though always with the mind of a child. The 
always must be emphasized. There is no known cure for the condition, 
and while, as above indicated, he may be trained to moderate usefulness 
and away from crime and misdemeanors, yet he is always a child. 

As to the recognition, aside from the idiot and low grade imbecile, 
there are only two or three types that are recognizable at sight. 

The hydrocephalic or large-headed person is usually though not 
always defective. At least the condition is enough to put the burden 



PREVENTING AND CONTROLLING MEASURES 



781 



of proof on the other side, i. e., one must convince oneself that a 
hydrocephalic is not feeble-minded before accepting him as normal. 



D 



O 



<5i5-r*5 



I I I I I 

« ? ? F F 



NEDS. 



Fig. 106 



* 87YRS - «78VW«. ALL ARE VERY OLD *6oTrS. 



-® 

4 88VR8. 
"CEREBRAL 
TROUBLE" 



©©02 



MENTALLY 
ABNORMAL 
LATE IN 
LIFE 



c5®& 



-no 







t 

Fig. 107 
Figs. 106 and 107. — Family history charts, showing hereditary feeble-mindedness. 



b-r-® 



D 



-® 






ALL UAHRICD 
DESCENDANTS NORMAL 






Fig. 108 
Figs. 106, 107 and 108. — Charts showing neuropathic ancestry. Squares, males; 
circles, females; N, normal mentality; F, feeble-minded; — under a symbol, in an insti- 
tution; T, tuberculous; E, epileptic; D, deaf; I, insane; d, dead; d, inf., died in infancy; 
horizontal line connecting a square and a circle, married; short vertical line connected 
by horizontal shows children of parents of parents above. (From Feeble-mindedness, 
Its Causes and Consequences, Courtesy of Macmillan & Co.) 

The microcephalic or small-headed person is practically always 
defective to a degree roughly proportional to the smallness of the head. 
A circumference of twenty inches has sometimes been given as the 



782 MENTAL DEFECTIVES 

dividing line between microcephaly and normal-headedness; but of 
course no sharp line can be drawn. 

The one type that is definite and that should be recognized by every 
physician is the so-called Mongolian. This has no connection with 
the Mongolian races except a more or less marked resemblance to that 
type of countenance, especially, in a thoroughly typical case, the 
obliquely set eyes. The following description from Shuttleworth will 
enable the physician to recognize the type, and once it is seen it is not 
easily mistaken: 

"In these cases the skull is a short oval, the transverse and longi- 
tudinal diameters approximating, while there is a tendency to parallel- 
ism of the frontal and occipital planes. Children of this type have a 
skin coarse in epidermis, if not furfuraceous; many have sore eyelids, 
some fissured lips ; but one of the most striking peculiarities is the state 
of the tongue, which is transversely fissured, and has hypertropbied 
papillae. Dr. John Thomson states that in the early weeks of life 
the tongue is normal; between the third and ninth months the papillae 
get enlarged, while during the third and fourth years the transverse 
fissures appear. This latter peculiarity is possibly due to tongue- 
sucking, which is so common in this type of defective, acting on 
an abnormally vulnerable mucous membrane. Many of them have 
almond-shaped eyes, obliquely set, and this feature, with the squat 
nose, epicanthic fold, and wiry hair, gives the mongol aspect from 
which they derive their name. The hands are usually broad and the 
fingers short, and often the little finger is incurved. The feet also are 
characteristically clumsy, with a marked cleft between the big toe and 
the next one. Laxity of the joints is a marked feature. There is 
reason to believe that they are essentially unfinished children, and 
that their peculiar appearance is really that of a phase of fetal life." 

It should be stated that the fissured tongue is not always present 
and one should not be in doubt about the diagnosis because of the 
absence of this feature. On the other hand its presence is determinative 
in otherwise doubtful cases. 

Mongolianism can usually be diagnosed early, age six or eight 
months, and sometimes even earlier. This should always be done for 
the sake of the parents. A diagnosis of Mongolianism settles several 
points: (1) The condition is not hereditary. (2) It is more frequent 
in the better families. (3) The child will never develop beyond about 
seven-year mentality and the great majority have a mentality of 
almost exactly four years. Consequently (4) they must always be cared 
for. Unpleasant as the duty is, yet in the long run it is a kindness to 
the parents to inform them of such a diagnosis. 

It has long been customary to regard the easily recognizable idiots 
and imbeciles as constituting a group apart from normal persons and 
as requiring special consideration. Only recently has it been appre- 
ciated that there is a large group not so easily recognizable, but, 
nevertheless, whose conduct is explainable on the basis of mental 
deficiency. Mental defectives are generally regarded as cases of 



PREVENTING AND CONTROLLING MEASURES 783 

arrested mental development. The phrase implies what is now under- 
stood as a fact, that the mind develops from birth to adult life much 
as the body develops; and just as the body may stop in its develop- 
ment, giving rise to the dwarf, so the mind stops, giving rise to the 
mental defective. 

It is customary to divide these defectives into groups according 
to the amount of mental development they have attained. Those who 
have the mentality of a two-year-old child or less are called idiots. 
Those of a mentality of from three to seven, are called imbeciles, 
while those who have attained to the mentality of a normal child of 
from eight to twelve, or perhaps to the beginning of puberty, are known 
as morons. Each of these classes may be divided into low, middle and 
high grade. In addition to these we have a group that are above the 
moron in mentality but whose conduct shows that they are not thor- 
oughly normal; for these no satisfactory term has been discovered. 
They are sometimes called dull normal, or backward. 

Obviously a person cannot be assigned to any one of these groups 
until it is ascertained that his development has actually ceased. A 
five-year-old child with five-year mentality is not an imbecile, because 
the assumption is that he will continue developing at the normal rate. 
Even if he has only the mentality of four or perhaps three, we cannot 
conclude that he is an imbecile because, while he is clearly below 
normal, there is a possibility that he may continue to develop, becom- 
ing at least a moron, and possibly dull normal or even average normal. 
Consequently the first problem for anyone who would deal with 
mental defectives is to ascertain as accurately as possible whether the 
person has already stopped developing. There is no known way of 
determining this in every case, but we have some empirical formulas 
that enable us to diagnose cases with all degrees of certainty from a 
mild suspicion up to practically complete assurance. 

Alfred Binet, who first suggested that it was possible to take the 
mental measure of such cases, and himself gave us a measuring scale 
for intelligence, deduced from his experience this somewhat crude 
formula: Children who are under nine years of age and show a back- 
wardness of more than two years, are probably mental defectives to the 
extent of being actually feeble-minded; those ivho are nine years or more 
and show a backwardness of more than three years are also feeble-minded. 

Experience has proved that as a rule Binet's formulas are well within 
the truth. Since his time, however, more accurate methods have been 
devised and we now use what is known as the Intelligence Quotient 
(called I. Q.). This is obtained by dividing the mental age, as it is 
called, by the chronological age, which of course gives, in the case of 
backward children, a fraction. If that fraction is less than 0.75 there 
is a very high degree of certainty that the person is feeble-minded. If 
the fraction is greater than 0.80 the person, while backward or dull 
normal, is not feeble-minded. If the Intelligence Quotient proves to 
be between 0.75 and 0.80, the case may be a doubtful one and is 
frequertly called "border-line," It will be seen that Binet's formula 



7M MENTAL DEFECTIVES 

as far as it goes agrees with this result. A child under nine, let us say 
eight, who is two years backward, having a mentality of six would 
have an 1. Q. of six divided by eight, or 0.75. If more than two years 
backward, his I. Q. would be less than 0.75 and he would therefore 
be defective. A person who was nine with a mentality of seven would 
have an 1. Q. of seven divided by nine, or 0.77 and is therefore just 
above the danger line. With a backwardness of three years, however, 
he would have an I. Q. of 0.66, which is well within the feeble-minded 
limits. The advantage of this formula is shown w 7 hen w r e come to the 
lower or the higher years. A child of four, for instance, with a men- 
tality of three would have an I. Q. of 0.75 and thus be a suspicious or 
border-line case. While with a mentality of tw r o and a half he would 
be distinctly feeble-minded. On the other hand a child of twelve who 
tested nine would be still a border-line case although fully three years 
backward. 

It is obvious that for the application of the intelligence quotient 
formula it is necessary to know the mentality w r ith considerable 
accuracy, just as it is necessary to use the chronological age with 
accuracy. It is customary to express the latter in years and tenths 
of a year and the mental age in the same way. The former is of course 
easily determined if we know the birth date. It is well to sound a word 
of warning here, however, because ofttimes parents either do not know 
the birthday accurately or have falsified it; as for instance, making 
the child older than he is so that he can get out of school and get his 
working papers sooner; or on the other hand making him younger, 
because they perceive his backwardness, and, being somewhat ashamed 
of it, wish to make out that he is not much behind his age. 

The mentality, "mental age" or "mental level," is now determined 
by some system of psychological tests. The best known of these is the 
Binet-Simon Measuring Scale for Intelligence, which, when carefully 
applied under favorable conditions by an expert psychologist, especially 
trained for the work, gives the mentality of the person to fifths of a 
year with a high degree of accuracy. In all doubtful cases, some such 
psychological examination should be given and the mentality deter- 
mined with as great accuracy as possible. However, it is often desirable 
to approximate the mental age when the facilities for making a psycho- 
logical examination are not at hand. It is usually possible to do this 
and the results are often sufficient for practical purposes. For instance, 
if a child of twelve seems to have a mentality of approximately six, 
lie i- obviously so definitely feeble-minded that a more accurate measure 
of his mentality is not necessary for the immediate purpose, though 
desirable for guidance in training. For unless one has made an error 
of at least three years, there is no possibility of the child's being normal. 

There arc several facts of easy determination that contribute to 
this approximate estimate of mentality. First is the school history. 
Careful studies have shown beyond question that school progress is a 
fairly accurate measure of intellectual progress. Most children enter 
school at six and advance a grade a year. This means that first- 



PREVEXTIXG AXD CONTROLLING MEASURES 



785 



grade work practically measures six-year intelligence; second-grade 
work, seven year; third-grade work, eight year; and so on. One has 




Fig. 109. — Twelve years, mentally seven. 


Fig 


110.- 


— Eleven years, mentally six. 


K^^W 








hI 






^Si^BSv V 


Wa " '"" J 






■ ^^y T*w J 


H v5 <« 






*St 


^^^ ^^1 






^^^ "** 


i 






m* *_w 



Fig. 111. — Twenty-six years, mentally 
ten. 
50 



Fig. 112. — Twenty-five years, mentally 
seven. 



r 86 MENTAL DEFECTIVES 






then only to ascertain what grade of work a child is doing in school 
to know whether he is doing the work that is proper for his age or 
whether he is backward. For example, a ten-year-old child should be 
doing fifth or at least fourth-grade work. If he is doing only third 
grade, he is decidedly backward; if only second, he is probably feeble- 
minded; if only first, he is surely so, provided of course he has been to 
school. Too much allowance, however, must not be made even for this 
lack. A ten-year-old boy who has just entered school may possibly 
be in the first grade, although even that is rather unlikely if he is normal, 
but if so, he will be doing his work w T ith an intelligence and progress 
that will enable the teacher to say without question that he is a normal 
boy. On the other hand, if the teacher's report is that he has difficulty 
with this first-grade work, one may be extremely suspicious to say 
the least; and it often happens that a child has not gone to school 
because of his deficiency, which is more or less recognized at home. 

Another criterion of considerable value, when an accurate deter- 
mination cannot be made, is the child's social reaction. If he has lived 
among other children, what grade or age of child does he prefer to 
play with? It is found that as a rule children prefer to associate with 
children of their own mentality rather than with children of their 
chronological age or even their physical size; so that if a child of ten 
prefers to play with children of six, it is very suspicious. Under this 
head may also be included the child's conduct, both social and moral. 
Does he act, talk, like a six-year-old child? Is he given to the moral 
conduct natural to a child younger than he is? 

Again, the physical examination will sometimes show more or less 
obscure stigmata of degeneration, of infantile conditions of one kind 
or another, and while these may no more than raise a suspicion, they 
are nevertheless often helpful especially when taken with the other 
criteria. Family history in many cases is exceedingly valuable. For 
example, if it is found that the child has brothers and sisters that are 
known to be feeble-minded, or if the parents, one or both, are recog- 
nized as low grade or degenerate, or if even more distant relatives are 
of this character, this lends a fair presumption that the child at least 
may be defective. 

What has been called practical knowledge is also of considerable 
worth in getting at this approximation of the mentality. To what 
extent does he know the things in his immediate environment which 
he might reasonably be expected to know? With younger children 
this is more difficult because most of us do not know just what children 
of the various ages notice in their environment. W T ith older persons, 
however, it often becomes a very significant sign, when it is found that 
the individual has not noticed and learned about the common things 
around him. 

With older persons the industrial history is significant. The amount 
earned is not always significant, partly because some of these high 
grade morons earn a very fair wage, and partly because it is difficult 
to ascertain just what the wage has been. If the person has ever by 



PREVENTING AND CONTROLLING MEASURES 



787 



accident earned a good wage or secured a job that paid a good wage 
even if he kept it only for a day, he will claim that he has earned so 




Fig. 113. — Twenty-five years, mentally 
nine. 



Fig. 114. — Sixteen years, mentally 
ten. 




Fig. 115. — Seventeen years, mentally ten. Fig. 116. — Twenty-five years, mentally 

nine. 



much. Along with this, however, and much more significant ofttimes, 
is the kind of work that he has done and the length of time that he can 



788 MENTAL DEFECTIVES 

hold a job. Some morons, it is true, are quiet and docile and patient 
and retain a job fairly well. But as a rule these people do not stay long 
OD the same work. Lacking self-control, judgment and good sense, 
they are very apt to get discharged for failure to satisfy the employer 
and arc quite as likely to throw up the job because of some real or 
imaginary difficulty or slight or offense, or because they hear of a job 
somewhere else. 

The case histories at end of chapter will illustrate this last point 
sufficiently. 

Another helpful line of investigation has to do with the cause of the 
condition. That is to say, in a case of suspected feeble-mind edness 
if there is any known reason why the person should be feeble-minded 
it offers some presumption that he is so. If on the other hand there 
is no known reason, this offers an equally good presumption against 
it. It will of course be appreciated that the presumption is not great 
in either case and is of no value except in connection with other facts. 
We have already alluded to the family history as possibly showing 
other defect ives in the family. This w T ould come under the head of 
"cause" since it is now T known that a large percentage, about 66 per 
cent., of feeble-mindedness is inherited. There is also quite a percentage 
of cases where, although there are no other feeble-minded in the 
family, there are a great many instances indicating an unstable nervous 
condition, which seems somehow to be transmitted to the child in 
the form of feeble-mindedness. 

Then we have diseases. While one can easily imagine that there 
are many diseases that might affect the brain so as to produce feeble- 
mindedness, as a matter of actual experience there is practically only 
one that has a demonstrably bad record and that is cerebrospinal 
meningitis. If a suspected case has had meningitis there is a rather 
strong presumption in favor of mental defect. Extremely severe 
attacks of certain other diseases, such as scarlet fever or malnutrition 
in early infancy, may also have some significance. On the other hand 
instrumental delivery does not prove to be a great factor. One needs 
to know very specifically the actual conditions of delivery in order to 
make it of any value. Partial strangulation with delayed animation 
seems to be rather more serious than the ordinary forceps delivery. 

Falls, blows on the head and other injuries are very uncertain and 
again must be described with very specific details so that one can judge 
rather closely as to the probabilities. When so judged and when 
compared with experiences of children who grow up to be normal 
these injuries do not prove to be very frequent factors. 

Syphilis and alcoholism in the parents do not seem to cause feeble- 
mindedness in the children. Recent studies show that syphilis in 
parents produces psychopathic children who often deteriorate men- 
tally to the feeble-minded level. But they should be carefully distin- 
guished from cases of true arrest of development — feeblemindedness. 

( Consanguinity has per se nothing whatever to do with feeble-minded- 
It' there is feeble-mindedness or bad nervous condition in the 



PREVENTING AXD CONTROLLING MEASURES 789 

stock, the bringing together of two branches of that stock doubles the 
liability of some undesirable condition appearing in the child. But 
the mere fact that the parents were cousins gives no presumption what- 
ever toward the child's being feeble-minded. It goes without saying 
that one should not make a snap judgment that a person is or is not 
feeble-minded on the basis of any one fact or expectation or prejudice 
or previous notion as to what constitutes feeble-minded ness. 

In what follows we have in mind the moron and high grade imbecile, 
as of most interest and importance to the reader. The idiot is well- 
known and seldom becomes a public problem, the low grade imbecile 
is so easily recognized and so obviously irresponsible and a subject 
for an institution that it is unnecessary to discuss him here. It is with 
the high grade cases that the medical officer can be most useful both 
to parents and to the public. 

As will be inferred from what has been said, the inexperienced person 
is most likely to conclude that a particular case is not feeble-minded. 
A recognition of some further characteristics of high grade mental 
defectives will help in this particular. It is very common to hear 
people cite some rather shrewd trick or action of a person and conclude 
from this that anyone who does such a thing is certainly not mentally 
defective. The conclusion does not follow. It is a familiar experience 
to all officers of institutions for the feeble-minded, that there are types 
of feeble-mindedness that show considerable shrewdness along certain 
lines. There are boys who can pick locks with great skill; there are 
many of them who show considerable aptitude along mechanical lines, 
especially if they have ever had the opportunity of being trained. 
Sometimes they show remarkable, or what appears to be remarkable, 
memory. Perhaps most deceptive of all is what we have called the 
loquacious type. There are boys and girls, men and women in years, 
who have a quite remarkable flow of language and if one does not 
listen attentively and examine critically their conversation, it is easy 
to conclude that they are average normal persons. Such critical 
observation usually discloses the fact either that their talk is mere 
gibberish or is the repetition of more or less intelligent phrases which 
have been picked up from the conversation of intelligent persons; a 
good memory, coming to their aid in such cases, enables them to store 
up these expressions for use upon occasion. Also some types are 
rather skilful in covering up their defects and in evading questions 
put to them to bring out their condition or tending to elicit incriminat- 
ing admissions. In The Criminal Imbecile 1 the writer has described 
three cases of very high grade feeble-minded persons who had com- 
mitted murder. All of these were typical high-grade cases and the 
description of them will help anyone to understand the possibilities 
of such cases. It may be noted further in speaking of criminals that 
all of these three confessed the crime. This is on the whole character- 

1 Macmillan, 1915. 



790 MENTAL DEFECTIVES 

Istic of defectives. While there are eases that stand out and resist 
all attempts to induce them to confess, yet as a rule, they seem to be 
rather proud of the execution of their crime and that pride rather 
quickly overcomes any fear and desire to escape; so that if carefully 
handled and their pride appealed to, they are very apt to confess and 
tell the whole thing in such a way that it is easy to convict. They 
are as a rule extremely suggestible as would be expected from the fact 
of their childish mentality. 

One thing that is particularly apt to deceive the inexperienced is 
the physical appearance. It is commonly supposed that a mentally 
defective person shows his defect readily, either in his physical form 
or in his movements or in the eye or some such outward expression. 
This is so often an entire mistake, that it is safest to conclude that there 
is nothing whatever in it. While it is true that those who have had long 
experience with the feeble-minded can usually detect them rather 
quickly, yet it is equally true that there are cases that deceive the very 
elect. Some of these people are as well formed and present as good 
an appearance as the average person one meets. While conversation 
would usually reveal the truth to the trained person, to the untrained, 
this is often passed over as being due to ignorance, and the person is 
considered illiterate rather than mentally defective. 

The general mental characteristics that can be determined without 
resort to psychological examination are (1) lack of control of their 
emotions and impulses, (2) inability to adapt themselves to new 
conditions, (3) inability to generalize from experiences or to deal with 
abstractions (4) general lack of good judgment and good sense. 

With such characteristics as have been pointed out, it is evident 
that these persons are a great menace to society. They are incapable 
of self-control and therefore easily yield to their natural impulses. 
Having few general ideas and still fewer moral principles, they are 
easily led astray by others. One of the criminals described in the book 
already referred to is a marked illustration of suggestion. He had no 
interest or motive in the murder he committed and did it entirely at 
the suggestion of an older and more intelligent man. Not only are 
mental defectives theoretically capable of all kinds of anti-social 
conduct, but careful studies have now shown us that these groups of 
criminals or delinquents are quite largely made up of mental defectives. 
It is believed that a large proportion, perhaps 50 per cent., of the 
inmates of our reformatories are feeble-minded. Even the adult 
prisoners in our penitentiaries are mentally defective to a large extent. 
Of the prostitutes that get caught and come before the court, fully 
50 per cent, are thus defective. Similarly with drunkards, hoboes, 
paupers and ne'er-do-wells. The failure to recognize these people 
as mentally defective costs the State annually thousands of dollars. 
They commit misdemeanors and crimes, the court convicts them, 
sends them to penal institutions for thirty, sixty or ninety days, or 
even a year or two; they serve their sentence and are set free only to 



PREVENTING AND CONTROLLING MEASURES 791 

repeat the same offense again. This is simply because they have no 
control over themselves and the very fact that they have done a deed 
once starts a habit and they do it again more easily. From the legal 
standpoint there is no justice in sentencing them for this crime or 
misdemeanor because they are not responsible. In terms of the usual 
legal question, "Did he know the nature and quality of his act and that 
it was wrong?" one has to answer; in the higher grade cases they 
probably know the nature and quality of the act, but they do not realize 
that it is wrong. It is true that they will say that it is wrong if you ask 
them the question, because they have learned to say that. They have 
heard it said that it is wrong, but they do not have any firm con- 
viction, any true realization of what it means to be wrong. 

In view of all this the question arises, how should such cases be 
treated? The answer is given briefly and nevertheless is remarkably 
accurate and significant. They must be treated as children. Whatever 
their age or experience in the world they are mentally children and 
when treated as such the best results are obtained. The writer has 
dealt with many a man and woman of perfectly normal appearance 
who maintained a reserve and dignity that was baffling until he 
approached them and talked with them as though they were children. 
Upon such treatment they immediately yielded and became talkative 
and natural, revealing their true mental state. When the question is 
answered from the social standpoint it means, of course, that these 
people must be cared for as children. This means, in the great majority 
of cases, segregation or colonization. In a certain percentage of the 
cases where the home environment is good and relatives of intelligence 
can exercise an oversight over them, and their temperament is favor- 
able, they may be allowed to live in their community, doing such 
work as their mentality will warrant, and will lead harmless and happy 
lives. 

It is rather a common notion that the feeble-minded are especially 
inclined to crime. In other words that they are naturally bad, vicious, 
wicked. This, however, is a mistake. As stated above, they are 
children and they are as innocent as children. It is true that they 
are easily made into criminals and when misunderstood and conse- 
quently mistreated, they are often driven to react and react in a 
criminal way. Not being able to take care of themselves or earn a 
living, they as a rule must either steal or become paupers. Not able to 
understand the ideas or ideals of normal associates, they are uncom- 
fortable in their presence and seek the association of those more nearly 
of their own level, often defective or degenerate adults. The result 
is that they easily fall into the same degenerate mode of life. But if 
they are recognized as defectives early in life and are cared for and 
trained and kept away from evil influences, they practically always 
become docile, tractable, happy, harmless people. 

It is the psychopathic cases of syphilitic origin above referred to 
that make the persistent delinquents of seemingly vicious tendencies. 



792 MENTAL DEFECTIVES 

The solution of this problem of mental defectiveness would seem to 
comprise therefore the following points: 

1. Because the condition is so largely hereditary, feeble-minded 
persons should never be allowed to marry and every precaution should 
be taken to prevent them from becoming parents. If this could be 
done, their numbers would be greatly reduced in a few generations. 
They could not be eliminated, as formerly supposed, since their hered- 
ity follows the Mendelian Law, which means that there will, for a long 
time to come, be feeble-minded persons born of parents who are 
apparently normal, but who, because there is defect in their families, 
may nevertheless transmit defectiveness. 

2. Those who are born must be early recognized and their status 
known, and they must then be trained in accordance with their men- 
tality. It is practically impossible to give them any of the ordinary 
school education. Some of the best of them may learn to read and 
write and occasionally they become somewhat proficient in these 
branches. As a rule, however, the time spent upon such subjects is 
wasted. They are highly trainable in industrial pursuits, such as do 
not require a high intelligence, and when thus trained they can work 
patiently and faithfully, and under supervision can often earn enough 
to pay for their support. Therefore physical and industrial training 
is indicated for them. Industrial training includes being taught the 
most elementary activities, such as personal cleanliness and hygiene, 
house work, farm work, and simple occupations. In cities there are 
many things in shops and factories that they can do if they are trained 
to do them beforehand. They cannot go into a factory, as a normal 
young man or woman does, and in a few hours or days learn to do 
the job that the overseer has for them. Under such conditions the 
overseer becomes disgusted with them long before they have learned, 
and they are discharged. 

3. Those who show tendencies that lead them into anti-social 
conduct such as sexual excesses, or who have no relatives or friends 
that are capable of controlling them, must be segregated in institutions 
or colonies. 

As to training, the special schools or the institutions are at present 
the only agencies that can carry on the work understandingly. There- 
fore our program should be to train them industrially as fully as 
possible and then to try them at work on probation, under careful 
supervision and oversight both when at work and out of hours. When- 
ever they show tendencies that cannot be thus controlled, they must 
be sent back to the institution to w T ork there the rest of their lives. 

The following case histories will help the reader to understand the 
moron: 

X. 1)., high grade moron, insane type, born, 1873, admitted 1891, 
discharged L897. Upon leaving the training school he joined the 
navy, three years, received honorable discharge. Did manual w T ork in 
Newark. Couple years later disappeared and for eight years no word 






PREVENTING AND CONTROLLING MEASURES 793 

of him received. Then letter received from Insane Hospital in Cali- 
fornia permitting his dismissal after two years a patient there. Upon 
his return to Newark he told of first six years away filled with many 
wanderings and different jobs. In Newark father and brother secured 
a job for him — manual labor for street railroad at $12 a week. Made 
much trouble; went with girls of bad character. Fanciful ideas 
weaved about truths told as facts. Boarded and roomed near brother's 
home. Father and brother tried to keep in touch with his companions 
and recreation. After three years they succeeded in placing him in 
hospital at Morris Plains. After a few months he ran away but was 
returned. After year and a half ran away again. Belongings sent to 
father contained horrible letters from girls. 

B. D., high grade moron, born 1900, admitted 1914, dismissed 1915. 
For a while lived with aunt in Hamilton, Ohio, worked in basket 
factory. He and mother went to Florida where he worked on farm for 
his mother. Cannot do very hard work, as not very strong. Worked 
at cement job, but too hard. Then worked in glass factory, melting 
down eye cups ($8 a week). "Work too hard," left there and grand- 
mother got work for him as general helper in kitchen at boarding house 
($2 a week and board). Could not keep him there as he was not a good 
worker and drank. Grandmother often had to help him, paying his 
board when he was out of a job. Finally implicated in chicken rob- 
beries, arrested and sent to the Rahway Reformatory. 

X. D., high grade moron, born 1887, admitted 1896, dismissed 1903. 
Big, fine-looking fellow. Went on visit to aunt in Atlantic City; 
wanted to stay and try position that was offered. Worked at several 
different places, first with uncle at carpentry ($1 a day). Then for a 
cousin who was a plumber. Then "drummed around" from one place 
to another. On police force at Atlantic City the last three years; on 
police force during the summer, and in winter worked at plumbing. 
"Pays his board, is honest and liked generally." Now in the army. 

D. E., low grade moron, born 1880, admitted 1898, dismissed 1899. 
For ten years lived at home and worked out at manual labor, such as 
digging, hauling, etc. Mother collected pay and provided clothes and 
spending money. Last eight years, since mother's death, works for 
woman who understands his mental condition; cares for horses and 
does hauling. Receives the equivalent of about $12 a week. Employer 
buys clothes and furnishes board and lodging (room in barn). Great 
weakness love of drink; not able to stand much. When he has money 
men easily persuade him into saloon. Resents any advance from 
sisters and brothers. 

H. T., high grade moron, born 1878, admitted 1888, dismissed 1892. 
Ran away from training school; walked to home in Newark. Begged 
so hard to remain home was allowed to do so. Has been a great care 
and made life miserable for all; was morally a menace to younger 
children. Mother prepared to turn him out if he did not improve. 
This had its effect. He reformed somewhat. Earned $15 and $18 



794 MENTAL defectives 

a week in shoe factory. Began to run with girls. At twenty-one 
married a girl and brought her home. Parents refused to keep him. 
Lived in rooms in wife's mother's home; no management; lived like 
pigs. Wife dressed extravagantly; picture of wife looked like actress. 
First child died as result of venereal disease; second child now four- 
teen in eighth grade. I\ loved to new home; took man lodger; much 
drinking; improper relations between lodger and wife. H. and wife 
quarreled; wife went home; H. drank heavily; lost his job; sent to 
prison; gotten out by aunt; leads most wretched life. Wife works in 
basement store; keeps daughter in school; has nothing to do with 
husband. 



CHAPTER XXX. 

MARITIME QUARANTINE. 

By LELAND E. COFER, M.D. 

Historical. — Quarantine (Lat. "quadraginta," Fr. quarante" — forty) 
has for centuries past been one of the numerous ways in which the 
public as well as the individual has manifested the natural instinct for 
self-preservation. 'Whether the individual or the public are familiar 
with the " quarantinable diseases," the result is the same when cases 
of smallpox, cholera, plague or yellow fever appear in their midst — 
they cry out, "Take it away," "quarantine it." In this manner has 
history been repeating itself since biblical times. In the book of 
Leviticus directions are given for the segregation, sometimes for stated 
periods, of lepers and in fact all persons suffering from skin diseases. 
There are other references in the Bible to precautionary measures 
ordered by the priests to prevent the spread of disease. 

Maritime quarantine originated much later in connection with the 
Levantine trade, and its early history was associated with that of 
shipping in the Mediterranean, especially with that of Venice and 
Marseilles. It is recorded that the pest at Constantinople, a.d. 534, 
was carried by ships and that this invasion of disease became later the 
foundation of the quarantine establishments on the Mediterranean 
coast. 

The Venetians were the first to make provisions for maritime 
sanitation. As far back as the year 1000 there were overseers of the 
public health. These officers were authorized to spend public money 
for the purpose of isolating infected ships, goods and persons on one 
of the islands of the lagoons surrounding the city of Venice. A medical 
man was stationed with the sick, and as a result of this arrangement 
the first thoroughly constituted maritime quarantine station of which 
there is historical record was established in 1403 on the island of Santa 
Maria of Nazareth at Venice. History tells us that the average 
maritime quarantine station of the sixteenth century consisted of an 
anchorage for vessels and barracks for suspects and convalescents and 
a place where " purification" could be applied. 

It will be interesting in this connection to relate what happened to 
a Catalan ship that arrived at Palermo from Barcelona on the way 
to Naples, which shows at least that the quarantine officers of the 
sixteenth century were thorough in their methods. The vessel carried 
97 persons, 18 of them passengers. Three seamen and two passengers 
had died of a disease suspected of being plague. The deaths occurred 
while the vessel was taking on cargo in the harbor where she lay at 



796 MARITIME QUARANTINE 

anchor. The carp) consisted of barrels of salted fish, cases of sugar 
(destined for Palermo and already unloaded and in the warehouse). 
salted cheese and general merchandise. The master of the vessel was 
first requested to give an enormous bond as security that he would not 
leave the harbor until given pratique, and to make his leaving still 
more difficult the rudder was removed from the ship and a watch was 
set. All persons except the sick and sufficient seamen to guard the 
ship were sent ashore, where all garments were taken from them and 
they themselves exposed to the fumes of boiling pitch and afterward 
washed with vinegar. Some of their clothing was burned and some 
was washed, aired and perfumed for fifty days. The sick were removed 
to the hospital and the cargo was treated as follows: The barrels of 
salted fish were washed outside, first with sea water and then with 
vinegar. The cases of sugar and salted cheese had their coverings 
removed and burned and the commodities, without further treatment, 
were delivered to the owners. Merchandise was aired and perfumed for 
fifty days and the cloth fabrics unrolled and hung from the rigging 
of the ship for fifty days. The sails and cordage of the ship were taken 
down, submerged in the sea for a week and then hung from the masts, 
yards and booms in the air, sun and dew by day and night as long as 
the ship remained in quarantine. The ship was then fumigated by boil- 
ing pitch in caldrons between decks. It is needless to say that the 
treatment of vessels infected with plague is not so complicated today. 
Organized quarantine in the United States was begun after the pas- 
sage in 1893 of the act (approved February 15, 1893) entitled: "An 
act granting additional quarantine powers and imposing additional 
duties upon the Marine Hospital Service." Prior to 1893 the various 
State governments, and later the county and municipal governments, 
as the case might be, conducted their own quarantine affairs as police 
functions. In those days one port would offer special quarantine 
advantages in the line of competition for trade or retaliate against a 
specific port with severe quarantine requirements. If space permitted 
much could be written along these lines, some of which would be 
amusing, showing the disadvantages of these varied systems of operat- 
ing quarantine in this country. However the passage of the above- 
mentioned act of February 15, 1893, showed that the people, through 
Congress, had decided that the system was faulty, a danger to the 
public health and a burden upon commerce. 



TYPES OF VESSELS MET WITH IN MARITIME QUARANTINE 

PRACTICE. 

The most important general classification of ocean carriers from a prac- 
tical quarantine standpoint is that of modern vessels as opposed to those 
ot the old type. The modern steam vessel is almost without exception 
large, with a general arrangement tending to the wide and distinct 
separation, by bulkheads and decks, of the three classes of passengers 



TYPES OF VESSELS IN MARITIME QUARANTINE PRACTICE 797 

on the one hand and the different departments of the ship's personnel 
on the other. Such vessels have high superstructures amidships, in 
which the first cabin passengers always and the second cabin passengers 
frequently live in a world apart from everyone else on board. The 
steerage passengers are usually quartered around the main freight 
hatches forward and aft below the spar deck and the seamen, firemen 
and mess men are on the same deck but in separate compartments 
amidships. The old type steam vessel, although carrying out our 
traditional ideas of what is nautical, is seldom large and is devoid of 
arrangement tending to a wide and distinct separation of classes and 
departments. The decks sweep gracefully fore and aft and the super- 
structure frequently affords direct communication with any or all 
parts of the ship. The quarters on such vessels are constructed with 
reference to the conservation of freight space, and the separation of 
classes on board is, from a quarantine standpoint, purely imaginary. 
Ocean carriers are classified for quarantine purposes as follows: 

1. Modern steam vessels. 

2. Old type steam iron vessels. 

3. Navy vessels and military transports. 

4. Steel sailing vessels and tramp steamers. 

5. Wooden vessels. 

Modern Steam Vessels. — The modern large steam vessels are rapidly 
replacing those of the old type on the transoceanic routes, and they 
are undoubtedly far safer, from a sanitary standpoint, than the old 
type of vessels. The large steamers are so expensive to maintain that 
their runs are quicker and their time in port much shortened, all of 
which has a bearing on the chances of their becoming infected with the 
intermediate hosts of certain of the quarantinable diseases. These 
vessels are equipped with all the modern appliances for ventilating and 
for the automatic flushing of latrines. Below the water line the hull 
is divided into compartments by water-tight bulkheads, which prob- 
ably limit the migration of vermin. Even the loftiness of the hull 
affords some protection against the ingress of vermin. 

Old Type Steam Iron Vessels. — The old type steam iron vessels 
present rather the reverse of the conditions enumerated above, and 
for this reason are classified separately in determining their probable 
status from a quarantine standpoint. 

Naval Vessels and Military Transports. — Naval vessels and military 
transports, while they do at times become infected with and are there- 
fore capable of carrying quarantinable diseases, are comparatively safe 
for the reason that commercialism enters nowhere into their conduct 
and every officer on board is officially and invariably the guardian of 
their sanitary integrity. 

Steel Sailing Vessels and Tramp Steamers. — Steel sailing vessels 
and tramp steamers usually make long voyages, visit many countries, 
have the carrying of freight as their sole aim and, in short, present the 
greatest hazard to the quarantine officer of any of the varieties of ocean 
carrier. 



798 MARITIME QUARANTINE 

Wooden Vessels. — Wooden vessels are placed in a class to them- 
selves, simply because once infected they present, on account of their 
construction, a great many obstacles to proper disinfection. All signs 
point to the complete substitution of steamers for sailing vessels, which 
fact lias an important bearing upon the practice of quarantine, for the 
reason that quarantine work in steamers presents far greater difficulties 
than in sailing vessels, steamers being more easily and more often 
infected than sailing vessels. 



THE QUARANTINABLE DISEASES. 

The diseases usually quarantined against in maritime quarantine 
practice are cholera, plague, typhus fever, yellow fever and leprosy. 
It is always good practice for the quarantine officer to notify the local 
health body of the presence of any and all communicable diseases 
arriving on vessels. 

The Inspection of Vessels. — The inspection of vessels is the most 
important part of quarantine practice. Successful maritime quarantine 
depends almost entirely upon its proper performance. In other words 
the inspection of a vessel holds the same relation to quarantine practice 
that the process of making a diagnosis does to medical practice. 

An inspection of a vessel includes the consideration of the sanitary 
history of all ports visited by said vessel, the present health status or 
quarantine credit of these ports, the inspection of all persons on board 
and the collateral evidence bearing upon the sanitary status of the 
vessel. 

The quarantine officer must be posted concerning the sanitary 
history and the present sanitary status of all the principal ports of 
the world, and should consider the bearing which the general sanitary 
history of a port may have upon the recent real or alleged health 
status thereof. 

The recent sanitary status of a port is learned through the United 
States Public Health Bulletin, through the Consular and other bills 
of health carried by the vessel, and from special information received 
either by wire or by letter from medical officers of the Public Health 
Service, or from Consular officers stationed at the ports previously 
visited by the vessel. 

The inspection of a vessel consists in the examination of all persons 
on board, and when necessary of the living compartments and holds. 

The first step in the inspection is an examination of all the sick 
persons on board. After visiting the sick, the bodies of any persons 
who have died at sea are viewed, and a necropsy performed if necessary. 
Suitable bacteriological examinations are made in all suspected cases 
of either plague or cholera. 

Next in order comes the general muster. The method and extent 
of examination of passengers and personnel of the vessel varies with 
the disease or diseases existing at the vessel's port of departure or 






THE QUARANTINABLE DISEASES 799 

ports of call. In the case of vessels from plague infected ports, a 
glandular examination of steerage and crew may be necessary. 

Even with a cursory inspection of a person standing in line, the 
boarding officer may detect any condition denoting illness not war- 
ranting the person's appearance at muster. This is mentioned because 
more than once men have been compelled to get out of bed and stand 
in line for the quarantine inspection. By a quick inspection such 
symptoms of leprosy as the claw-hand, drum-stick-fingers, elongated 
or nodular ear lobes and frontal or cutaneous thickening may be seen. 
Cutaneous eruptions of any description naturally suggest a further 
examination with a view of fixing or eliminating a diagnosis of variola. 
Unusual or marked cases of "sea-sickness" from cholera-infected 
ports naturally demand further investigation. Cases of pneumonia, 
either acute or convalescent, from plague-infected ports are examined 
especially for the presence of the plague bacillus. 

The formal inspection of the vessel having been completed the 
boarding officer collects the collateral evidence as to the ship's sanitary 
status. The collateral evidence includes the general condition of the 
hull and the living quarters, the character and condition of the sanitary 
arrangements, and the condition of the decks and holds as to general 
cleanliness. It also includes the possible finding of dead rats during 
the voyage. 

The source of water and vegetable supply and the kind of cargo 
carried are also considered in the light of collateral evidence. 

The Diagnosis or Judgment of the Vessel. — The last step, the 
judgment of a vessel's health status, is arrived at by weighing the 
findings of the inspection, that is, the conditions which were apparent 
at the time of inspection against the possibilities of concealed infection 
or latent infection. 

Either concealed or latent infection or even both of these conditions 
may apply to a ship itself or to the personnel. Concealed infection is 
usually concomitant with dishonest or ignorant masters or captains 
or with wily passengers and crew. Latent infection is a condition 
dependent upon the character of a vessel, her conduct while in an 
infected port, and upon the character of the quarantinable disease 
present in such ports. 

When a captain of a vessel compels men sick with a quarantinable 
disease to stand in line to pass inspection, or makes a false certificate 
regarding the finding of dead rats on board during the voyage, he 
may be said to be concealing infection. On the other hand when a 
passenger or member of the crew has had a very mild, modified, or 
attenuated attack of a quarantinable disease which has escaped all 
notice, the disease on the ship may be said to be latent. 

The determination of concealed or latent infection on vessels can- 
not be learned from books; it must be acquired or absorbed by long- 
continued experience and observation. 

Concealed or latent infection is the cause of most of the failures in 
maritime quarantine work, therefore it frequently happens that a 



800 MARITIME QUARANTINE 

hoarding officer is forced in the interest of public safety to impose the 
burden of proof as to the absence of latent or concealed infection upon 
the vessel. 

The facts which may be gathered by the ordinary inspection of a 
vessel comprise the information obtainable from the bills of health 
and the ship's papers, and the sanitary facts gathered by the boarding 
officer. 

The apparent presence or absence of quarantinable disease is the 
most that can be determined by an examination of the vessel and its 
personnel. Instances are rife where careful and conscientious boarding 
officers have failed to detect cases of quarantinable disease in passengers 
who by means of careful planning were able to evade inspection. 

The boarding officer must render his decision as to the vessel's 
status immediately after inspection, and the inspection must afford 
protection to the community and yet act as a sieve, not as a dam to 
commerce. 

If the quarantine officer only had the facts above enumerated to 
consider, an opinion would always be prompt and probably exact, but 
the hazard of latent or concealed infection to w r hich a large steamer, 
en route perhaps ten days from an infected port is liable, renders a 
decision possible only after consideration of the following conditions: 

1. The probable sanitary history of the voyage. 

2. The likelihood of latent infection. 

3. The possibility of concealed infection. 

4. The kind of cargo carried. 

The probable sanitary history of the voyage involves the hazard 
of way port traffic; for example, if one hundred passengers of unknown 
origin board a vessel in Genoa and land two days later in Naples, their 
presence on board may or may not have altered the sanitary status of 
the vessel, but the number, origin and destination of the passengers 
together with the known sanitary conditions of the ports involved 
would raise a question in the boarding officer's mind upon the arrival 
of the vessel in the home port. 

Latent plague infection, the likelihood of which must be reckoned 
with, could be caused by an infected rat being introduced into the 
vessel with the freight, or by the embarkation of a passenger suffering 
from ambulant plague. The passenger himself might recover from 
the illness without attracting attention and yet leave infection to 
spread later on. 

The Kind of Cargo Carried. — A cargo is dangerous according to its 
general character. Coal, oil, ore, nitrates and the like are safe cargoes, 
while flour, cereals, grain and foodstuff are apt to harbor vermin and 
are therefore open to question. General merchandise is dangerous, but 
principally because the spaces which usually intervene between the 
parcels may harbor vermin. 

A vessel may be found a safe risk in every other respect save in the 
cargo. A decision pending upon the status of the cargo is a difficult 
one to make, as on the one hand the public health may suffer and on 



DISINFECTION IN MARITIME QUARANTINE PRACTICE 801 

the other hand the vessel may be put to needless expense if quarantine 
treatment is not necessary. After all, the boarding officer must judge 
cargo by the possibility of its affording a habitat for the intermediate 
hosts of quarantinable diseases. 

In short, the judgment of a vessel's status can only be obtained by a 
process of deduction, and the most successful boarding officer is the 
one who forms the largest number of correct deductions. 



THE SEGREGATION OF PASSENGERS AND CREW. 

In maritime quarantine practice suspected or infected vessels, together 
with all persons and effects on board are subjected to what is known as 
quarantine treatment. Under quarantine treatment, disinfection as 
a function and process is properly placed, and will be described else- 
where. 

All persons suffering from quarantinable diseases are first removed 
from the vessel and placed in the contagious disease hospitals, the 
quarters just vacated by them being immediately subjected to fumi- 
gation by sulphur or hydrocyanic acid gas. 

Next comes the removal if need be of first class, second class and steer- 
age passengers in regular order. 

After all persons have been removed from the vessel, the latter is 
subjected to a process of disinfection. 

The treatment of persons from infected vessels varies with the 
kind, class, and number of the passengers, with the arrangement of 
the living quarters of the vessel, the type of vessel, the condition at 
the home port or port of arrival, and with the disease involved. Differ- 
ent classes of passengers may or may not have their effects disinfected 
according to circumstances. 



DISINFECTION IN MARITIME QUARANTINE PRACTICE. 

The treatment of baggage and personal effects. — Baggage and 
personal effects are disinfected by means of steam in steam chambers 
with or without formaldehyde. 

The disinfection of fabrics, clothing and bedding in quarantine 
practice is usually accomplished by the use of either steam or formal- 
dehyde in the usual double jacketed chamber with jetting steam or 
steam under pressure with formaldehyde gas alone or in combination 
with dry heat; also with a combination of these methods with or 
without a vacuum. The chamber is built with an inner and an outer 
shell. The steam jacket when heated prevents the condensation of 
steam in the disinfecting chamber by heating the latter before the 
steam is turned on. This prevents the wetting of the clothes and other 
articles to be disinfected. In using the chamber with steam, either with 
or without pressure, the steam is kept continually coursing through 
51 



802 MARITIME QUARANTINE 

the jacket. The chambers should be loaded with care, the clothes 
should be hung up in the disinfecting cars and under no circumstances 
stuffed in. Clothes are usually loosely arranged in wire baskets or 
gunny sacks, which are then neatly arranged in the disinfecting car. 
The baskets or gunny sacks are numbered with metal checks with 
duplicates, the latter to be held by the owner of the baggage during 
the process of disinfection. 

The treatment of the vessel. — The disinfection of a vessel requires 
on the part of the disinfector some familiarity with the general arrange- 
ment of the interior of vessels and a certain amount of ingenuity. 
A vessel is seldom so badly infected as to require disinfection through- 
out. The hazard of an infected vessel varies according to the nature 
of the disease with which it is actually or presumably infected. There- 
fore, it is very frequently difficult to decide just what part of a vessel 
and just what personal effects should be disinfected. There is no 
reason why the staterooms of the first cabin passengers should be 
disinfected because there is a case of smallpox in*the steerage or in the 
quarters of the crew. Likewise, there is no reason to disinfect the holds 
of a vessel and break the cargo in bulk because of a case of smallpox, 
cholera or typhus fever found in the cabin or steerage. Therefore, an 
infected vessel requires definite and especial quarantine treatment 
according to the nature of the disease with which it is infected. For 
example, in vessels infected or suspected of infection with cholera, 
especial attention must be paid to the drinking water on board, and the 
vegetables and fruit as well. In the case of plague, the destruction 
of rats and other vermin is of first importance. For yellow fever, 
measures must be taken against the presence of mosquitoes, (Aedes 
Calopus) and for smallpox and the eruptive fevers, the usual disinfection 
of living apartments, clothing, bedding and the personal effects of those 
exposed to infection is required. 

After the quarantine officer has made a thorough inspection of the 
vessel he can determine the exact extent to which he will carry the 
process of disinfection. Such rooms as the carpenter shop, chain 
lockers, rope and sail lockers, lamp lockers, paint rooms, chart rooms, 
pilot house, engine and boiler rooms, machine shops, shaft alley and 
turtlebacks are usually not infected and therefore require no disin- 
fection. It may be necessary, however, to fumigate these places for the 
destruction of rats and mosquitoes. The dining-rooms, social halls 
and smoking rooms usually contain a great deal of metal and gilt 
decorations, which are ruined by sulphur; therefore, the metal and gilt 
work in such compartments, when fumigation is required, should be 
protected by a coating of vaseline. 

The agents principally used in the disinfection of a vessel are sulphur 
dioxide, hydrocyanic acid gas, formaldehyde gas and bichloride of 
mercury. 

Sulphur Dioxide.— This is the most efficient of all of the disinfectants 
30 far as the holds of a vessel or compartments are concerned. It is 






DISINFECTION IN MARITIME QUARANTINE PRACTICE 803 

equally destructive to animal and vegetable life, and it is therefore 
invaluable in quarantine practice in destroying contagion that is trans- 
mitted through the agency of mosquitoes, flies, bedbugs, rats and 
mice. Its action requires the presence of moisture in some form. The 
gas diffuses slowly and has very little penetrating power, therefore 
the use of sulphur gas should be limited to the disinfection of surfaces, 
it being unsuitable for the disinfection of bedding, mattresses and 
fabrics. It does not kill spores, and therefore is inapplicable to disease 
caused by spore-forming organisms. It should be borne in mind that 
sulphur gas bleaches all fabrics colored with vegetable dyes, and has a 
disintegrating action upon cotton and jute fabrics, such as sugar and 
fertilizer bags. In computing the amount of sulphur required for the 
disinfection of holds and compartments of vessels, the following rules 
should be remembered. One pound of sulphur burned in a space con- 
taining 1000 cubic feet will produce 1 per cent, of the gas. Five pounds 
of sulphur burned in a space containing 1000 cubic feet will produce 
5 per cent, of the gas. This latter volume strength of gas is sufficient 
to kill all non-sporebearing organisms after sixteen hours' exposure. 
With 2 pounds of sulphur for every 1000 cubic feet, two hours' expo- 
sure is sufficient to kill mosquitoes and vermin. In disinfecting with 
sulphur all spaces must be rendered air-tight. 

Hydrocyanic Acid Gas. — This gas is produced for ship fumigation 
by acting upon sodium cyanide with a mixture of sulphuric acid and 
water. For each 1000 cubic feet of space 3f ounces of sodium cyanide, 
5j-q ounces of sulphuric acid and 7 T 5 ^ ounces of water are used. For 
large spaces such as holds, barrels are used as generators; for small 
spaces such as storerooms, forecastles, cabins, etc., buckets are used. 
One hour is the time officially allowed for reaction, diffusion and 
penetration of the gas, after which the space is opened as widely as 
possible and ventilation encouraged. In fair weather and with a good 
wind and other favorable conditions, the clearing out is accomplished 
within a half hour; under cloudy and unfavorable conditions, not for 
an indeterminate number of hours. This gas is fatal to all kinds of 
animal life, is quick in action and is admirable as a time saver in ridding 
ships of rats and vermin, but it is extremely dangerous to human life 
and should only be used by responsible and careful persons. At the 
port of New York considerable fumigation has been effected by vapor- 
izing liquid hydrocyanic acid. 

Formaldehyde Gas. — In quarantine practice this gas is most con- 
veniently and efficiently used by means of the autoclave. By the use 
of the autoclave, the gas is produced from a solution under pressure 
and not only is the gas evolved in a short time, but good penetration 
and diffusion are obtained. The solution used consists of formalin 40 
per cent., with 20 per cent, of calcium chloride, or some other neutral 
salt such as common table salt. Ten ounces of the solution should be 
used for each 1000 cubic feet of space to be disinfected. The exposure 
period for holds or compartments is from five to twelve hours. Fabrics 



804 



MARITIME QUARANTINE 



hung up loosely in a compartment may be disinfected by an exposure 
of twelve hours. Formaldehyde gas is being used less and less in 
quarantine practice. 

Bichloride of Mercury. — This agent should be kept on band at 
Quarantine Stations in a tank with a capacity of at least 2000 gallons. 
The strength should be 1 to 1000. This solution is used in the form 
of a spray as a surface disinfectant. 

The foregoing is barely an outline of maritime quarantine practice, 
which is changing as to conditions constantly and which must vary 
with and according to a large number of influences. 



CHAPTER XXXI. 

VITAL STATISTICS. 

By WILLIAM H. GUILFOY, M.D., 

AND 

SHIRLEY W. WYNNE, M.D. 

Statistics may be defined as the science of dealing with large 
numbers and presenting them in such a manner that the mind can 
easily grasp their meaning. Webster defines statistics thus: "Classi- 
fied facts representing the conditions of people in a state, especially 
those facts that can be stated in numbers, or in tabulation or classi- 
fied arrangement.". Bowley defines statistics as "the science of the 
measurement of a social organism regarded as a whole, in all its mani- 
festations." Statistics includes counting, segregating, tabulating and 
analyzing collected data; making estimates, e. g., of populations, of 
crops, of mine outputs, etc., and lastly presenting these results in a 
readily understandable manner. King gives the following definition 
of statistics: "The science of statistics is the method of judging 
collected, natural or social phenomena, and the results obtained by 
the analysis of an enumeration or collection of estimates." 

Vital statistics is that branch of the science that deals with the 
phenomena of the life of people, that is, births, marriages, illness and 
deaths, populations and the movement of populations, and may be 
defined as the bookkeeping of the health of a community or a nation. 
Newsholme has defined vital statistics as the science of numbers 
applied to the life-history of communities and nations; Wilbur calls it 
the Cinderella of modern public hygiene, sitting in the chimney corner 
sifting the ashes of dusty figures while the proud sisters, bacteriology 
and preventive medicine, go to the ball and talk about the wonderful 
things that they have done. It might also be defined as the numerical 
registration and tabulation of population, marriages, births, diseases 
and deaths, coupled with analyses of the resulting numerical phe- 
nomena with the end in view of " searchlighting " the path of sanitary 
progress. 

Purpose of Vital Statistics. — Statistics, in general, are used as a 
guide to appropriate action in the efficient conduct of a business or of 
a government. Vital statistics are used as a guide to appropriate 
action in the maintenance and improvement of public health. With- 
out vital statistics, a health officer would be unable to compare the 
health conditions in a community under his supervision with those 
previously existing or with similar conditions in other communities. 



806 VITAL STATISTICS 

He would be unable to determine whether his efforts toward the 
reduction of illness and death were meeting with success. He would 
be unable to determine whether or not the public moneys entrusted 
to his care were being judiciously and wisely expended. He would 
be unable to present concrete evidence of the health needs of a com- 
munity in support of a budget he may be submitting to an appropriat- 
ing body. In making a plea for funds for health purposes, it is abso- 
lutely essential that one be able to present irrefutable evidence of 
the needs of the health work for w r hich the funds are requested. Vital 
statistics, "the chart and compass of the sanitarian" alone can supply 
such evidence. A health officer, if he is to discharge efficiently the 
duties of his position, must have knowledge of the presence and 
location of preventable diseases in his community: (1) In order to 
check the spread of disease; (2) for epidemiological study; and (3) to 
determine and develop general policies for the reduction of the inci- 
dence and mortality of these diseases. He must have knowledge of 
the incidence and mortality of all causes of death, if he is to inaugurate 
campaigns against them and to measure the success of the methods 
adopted. For such knowledge, he must have recourse to vital statis- 
tics. It is evident, therefore, that every health officer should have a 
thorough understanding of the fundamentals of vital statistics, and, 
it will be our endeavor in the following pages, to set forth in a simple 
and readily intelligible manner, those things which are of primary 
importance. We shall deal with the subject matter in the following 
order: Population, marriages, births, deaths, rates and illness. An 
appendix will be devoted to the more technical statistical methods in 
order that the ambitious health officer may obtain further knowledge 
that will enable him to compare, analyze and present his statistics in 
a correct and scientific manner. Not a few proverbs or trite sayings 
have been applied to statistics. Perhaps those, most often heard are 
the following: ''Figures can be made to prove anything— figures 
won't lie." "Statistics are often cut on the bias." "Statisticians, 
consciously or unconsciously, twist figures to fit the case." Most of 
these proverbs, however, have been disparaging to statistics and they 
reflect the attitude of the public mind toward the trustworthiness of 
statistics. The untrustworthiness that is at times found in statistics 
is not inherent in statistics themselves, but is rather a reflection of 
the ignorance or wilful untruthfulness of the interpreter. Unfortun- 
ately, a casual reader is unable to determine the results presented, 
the degree of accuracy of the basic data or to judge the truthfulness 
and ability of the author. Then, again, the data and tabulations 
may be entirely trustworthy, but the analyzer may have wrongly 
interpreted their meaning. Still, again, in carrying forward a statisti- 
cal investigation, one is apt to let one's prejudices or preconceived ideas 
on the subject under investigation, influence one's, judgment in the 
interpretation of the data or in the analyses of the results. On the 
other hand statistics conscientiously prepared often batter down 
existing fallacies. We may, therefore, lay down the following rules: 



HISTORY OF VITAL STATISTICS 807 

(1) Basic data should be accurate. If there is a possibility of error 
that cannot be corrected, the author should call attention to this 
possibility of error, and state the source of his information, in order 
that the persons studying his statistics may not be mislead. If, in 
the course of statistical study, it becomes necessary to use the data 
that has been collected by someone other than the author, the source 
from which the author has secured the information, should be stated, 
first, as a matter of fairness, and second, in order that the persons 
interested in his study may be able to refer to the original source of 
information, and they themselves judge of its truthfulness. (2) All 
statistical problems must be studied by an unprejudiced mind and in 
a scientific and unbiased manner. (3) Comparisons based on statistics 
should have an elementary foundation in common and if modifying 
factors exist, same should be stated or what would be much better cor- 
rected mathematically. (4) Quantities dealt with must be numerous 
enough to warrant proper deductions to be drawn therefrom. 

History of Vital Statistics. — The earliest record of an approach to 
the use of statistics of population is to be found among the Egyptians; 
in the Bible, II Book of Samuel, xxiv, 1-9, King David commands Joab 
to number Israel and Juda with resulting report of 800,000 Israelites 
and 500,000 Judeans, it having taken nine months and twenty days to 
finish the enumeration; the Greeks took many censuses, vital and 
material; the Romans at the time of the Empire took a census every 
five years for a period of three hundred and fifty years and kept 
records of births and deaths, but as far as we are able to judge did not 
put the material to the practical uses in which modern vital statistics 
are employed. 

Censuses were not taken during the Middle Ages. John Graunt 
was the first statistician to publish a table of mortality based upon 
the death registers of London, which were begun in 1592 and con- 
tinued with additional data to the same for many years. 

Halley the famous astronomer was the first individual to prepare 
a life table based upon the tables of births and funerals in the city of 
Breslau and published in the year 1693. 

Deparcieux, in 1746, " published an essay on the "Probabilities of 
the Duration of- Human Life," based upon tables of mortalities of 
French annuitants. 

Dr. Price, in 1783, constructed a life table based on the population 
and deaths in Sweden and Finland, this being the first national life 
table published. 

Milne constructed the so-called Carlisle Table based on the popu- 
lation and deaths in Carlisle during the nine years 1779 and 1787, 
the treatise being published in 1815. 

Dr. William Farr, the father of modern vital statistics prepared 
and published three life tables: The first appeared in the Registrar- 
General's Fifth Annual Report (1843), and was based on the deaths 
in England and Wales in the year 1841; the second was published 
in the Registrar-General's Twelfth Annual Report (1853) and was 



80s VITAL STATISTICS 

based on the deaths in England and Wales in the seven years, 1838- 
L844; the third was published as a separate volume in 1804 and was 
based on the mortality in England and Wales during the seventeen 
years, 1 S is is.") I. The following quotation from Dr. Farr's is taken 
from the Fifth Annual Report mentioned above and the contemplation 
of the unparalleled sacrifice of human lives in the greatest war of all 
times is offered as an excuse for its insertion: "Since an English life 
table has now been framed from the necessary data, I venture to 
express a hope that the facts may be collected and abstracted, from 
which life tables for other nations may be constructed. A compari- 
son of the duration of successive generations in England, France, 
Prussia, Austria, Russia, America and other States, would throw much 
light on the physical condition of the respective populations, and 
suggest to scientific and benevolent individuals in every country — 
and to the Governments — many ways of diminishing the sufferings 
and ameliorating the health and condition of the people; for the 
longer life of a nation denotes more than it does in the individual — a 
happier life — a life more exempt from sickness and infirmity — a life 
of greater energy and industry, of greater experience and w T isdom. 
By these comparisons a noble national emulation might be excited; and 
vital nations would read of sickness diminished, deformity banished, 
life saved — of victories over death and the grave — wdth as much 
enthusiasm as of victories over each other's armies in the field; and 
the triumph of one would not be the humiliation of the other; for in 
this contention none could lose territory, or honor, or blood, but all 
would gain strength." 

Life tables were published by the German Imperial Statistical 
office in 1910, by the Registrar General's office of England in 1907-1908 
and in 1916 by the U. S. Census Office. 

The most important books upon the subject in English are Vital 
Statistics by Wm. Farr, M.D., published in 1885 by the Sanitary 
Institute of Great Britain; Vital Statistics by Arthur Newsholme, M.D., 
published in 1899 (third edition) by Swan Sonnenschein •& Co. Ltd., 
London, New York agents The Macmillan Co.; an excellent pamphlet 
on the subject written by Dr. John W T . Trask, Assistant Surgeon- 
General, U. S. Public Health Service, has been issued as supplement 
Xo. 12 to the Public Health Reports and can be obtained for the 
asking from the U. S. Public Health Service, Washington, D. C. 

Essential Requisites of Vital Statistics. — There are two essential 
requisites for the preparation of vital statistics, two pillars upon 
which rest the superstructure of the subject, (1) the population as 
ascertained by the census or enumeration officials and (2) the returns 
of births, marriages, sickness and deaths. The statistics of the 
population must be classified according to sex, age, civil condition, 
color or race, occupation; and the births, deaths, sickness and marriage 
certificates or returns must be arranged in tabulations showing similar 
items to those called for in the population schedules so that ratios or 
numerical relations between both may be established. 



CENSUSES 809 



CENSUSES. 



The first census of modern times was taken in 1751 in Sweden and 
Finland; in 1790 the United States of America took its first census and 
every ten years thereafter; the thirteenth was taken in 1910. The 
first census taken in England was in 1801 and repeated decennially; 
the twelfth was taken in 1911. 

Some of the Continental countries take censuses every three, and 
others every five years. 

The increase in the population between censuses is called the actual 
increment and reflects the addition to it from all sources; the natural 
increment is the excess of births over deaths. 

Errors in the Census. — In taking a census a number of errors 
are apt to creep in. The most common one and that of greatest 
interest to health workers, is the error in the statement of the ages by 
the persons enumerated. There is a strong tendency in women to 
understate their ages and examination of the census returns shows 
concentration of the female population at the early twenties, most 
noticeable among single women. Among elderly persons there is a 
tendency to overstate their ages. Among the less educated, par- 
ticularly, there is a tendency to state their ages as a multiple of ten, 
that is, if they are thirty-eight or thirty-nine or forty-one or forty-two 
to give their age as forty. There is a lesser tendency to state ages 
in years ending in five, as twenty-five, thirty-five and forty-five. To 
overcome these two errors, it is customary to divide the population 
into ten-year frequency groups, ending with the fifth years, rather 
than with the "0" years. By this method the population is more 
evenly distributed. The concentration of the population at the 
"0" year is clearly shown in the accompanying table which has been 
taken from Bailey's "Modern Social Conditions," and by him, taken 
from the report of the Federal Bureau of the Census: 

NUMBERS OF PERSONS OF NEGRO DESCENT IN THE UNITED STATES 

IN 1900. 

Age. Males. Females. 

68 years 7,924 6,688 

69 " 7,071 5,982 

70 " 20,224 22,908 

71 " 3,271 2,645 

72 " .- 4,994 4,146 

Another error that is encountered in the census is due to the ten- 
dency of parents to state the ages of children under one year of age, 
as one year old, thus unjustly increasing the group between the age 
of one and two and decreasing the group under one year of age. For 
this reason it is inaccurate to base infant mortality-rates upon the 
population under one year obtained at the census. This matter will 
be further discussed in the paragraphs devoted to infant mortality. 
Still another serious error is encountered in the statements of occu- 
pation: In order that the effect of employment upon health and life 



S10 



VITAL STATISTICS 



may be studied it is necessary not only to state the occupation itself 
but also 1 1 it- nature of the industry and, if possible, the length of 
time engaged in such occupation; otherwise the error will be made 
of comparing sickness or mortality of persons engaged in one occupa- 
tion with those engaged in another but with the same general designa- 
tion, the hazard being entirely different in one occupation as com- 
pared with the other, as for instance, a laborer in a general merchandise 
store with a laborer in a lead factory. The duration of employment 
in present and previous occupations should be stated because indi- 
viduals whose health has been undermined by means of employment 
in hazardous occupations obtain entrance into lighter and less 
hazardous callings. 

As we have already pointed out in a previous chapter, and as is 
shown in the accompanying diagram, the mortality changes from 
year to year of life, and since the age distribution of no two communi- 
ties is exactly alike, it is apparent that we must have accurate knowl- 
edge of the age distribution of a community before we can compare 
justly its mortality with the mortality of another community. 





DEATH RATES, NEW YORK CITY 










BY AGE GROUPS, YEAR 1916 








100- 








-100 


a. 95- 








-95 


O 90- 


{ 






- 90 


§85- 








- 85 


u 80- 








- 80 


S75- 








- 75 


i 70- 








- 70 


£65- 








- 65 


u 60- 








. 60 


$55- 








- 55 


o 50- 








- 50 


|45- 








- 45 


3 40- 








- 40 


§35- 
° 30- 








- 35 








-80 


oc 25- 








- 25 


o! 20- 








- 20 


£ 15 ' 








- 16 


H 10- 








- 10 


<r 5- 









- 5 




112 3 4 5-9 10-U 15-19 20-2423-29 30-34 3^39*)^4=45-f950-r4 55^5^60-64 65-69 ana 


ver AGE GROUPS 




~r.Yr.Yr.Yr. 









Fig. 117 

It is common knowledge that populations of newly settled com- 
munities are apt to have an abnormally large percentage of young 
males, for the reason that unencumbered males are the first to emi- 
grate and to risk the hardships of pioneer settlements. Communities 
that are slightly older, have an excess of both males and females 
between the ages of twenty and forty-five, because persons beyond 
forty-five years of age, are usually unwilling to risk the chances of 
unemployment and the discomforts and hardships encountered in 
newly settled communities. As communities grow older, children are 
born and the population is then composed of persons in middle life and 
children of early ages. 

Since, as we have seen, sex, age, marital condition, etc., influence the 
the frequency of births, marriages and deaths, it is evident that we 



CENSUSES 811 

must, in order to study these phenomena, know the total population in 
which they occur, and the number of persons in that population at 
each age, the number of each sex, the number of single, married and 
widowed persons, and the number of persons engaged in the various 
occupations, and this information can only be obtained by census. 
But since the censuses are taken at intervals of five or ten years, it 
becomes necessary to estimate the populations for intercensal years. 
There are two standard methods of estimating populations, to wit., 
arithmetical and geometrical. The arithmetical method sjmply con- 
sists in finding the annual increase in the population between two 
censuses, and its addition to or subtraction from the figures of the 
last census to determine the number of persons in the population 
during a intercensal or postcensal year, as shown in the following 
example : 

Population by census of June 1, 1900, 200,520. 

Population by census of June 1, 1910, 250,630. 

Increase in population in ten years, 50,110. 

Increase in population in one year, 5011. 
If population of city in 1910 was 250,630, what will it be in 1911? 
Answer, 250,630 + 5011 = 255,641; in 1912 it will be 255,641 + 5011 
= 260,652 and so on; if desired the population at any year between 
the census years may be ascertained in a similar manner. If the 
population in 1910 was 250,*630, what was it in 1905? Answer, 
250,630 — 25,055 (that is five times the annual increase) = 225,575. 
As the estimates of the population by this method are based on 
the assumption that the amount of annual increase between, census 
years will continue during the postcensal years and as it very seldom, 
if ever, does it become necessary on the receipt of the figures obtained 
at the next censal enumeration to recast or correct the estimates and 
to recalculate the rates for those years. The arithmetical method is 
the one in use by the Bureau of the Census at Washington, D. C, and 
as is evident by the preceding example is easy of application. The 
geometrical method is, however, more approximately correct in 
certain instances and as it requires a slightly higher grade of mathe- 
matics, it will be described in the appendix to this chapter. 

Marriage Statistics. — Marriage statistics are of value from legal, 
social and a public health viewpoints. We will discuss the value of 
marriage records from the viewpoint of public health first. 

The number of marriages in a community has a direct relation to 
the legitimate birth-rate, and since the population is depleted by 
deaths and replenished by births, the importance of marriage statis- 
tics is apparent. The data usually contained in marriage certificates 
or reports that are of interest to the health officer are age, color and 
the nationality of the persons married. From a social viewpoint, 
marriage statistics are of importance since the}' shed light upon the 
prosperity and morality of the community. From a legal viewpoint 
marriage statistics are of importance because of the many uses to 
which they are put, e. g.: 



812 VITAL STATISTICS 

1. In proceedings for divorce or separation the marriage of the 
complainant to the defendant must be established* 

2. A record of the second marriage before the dissolution of the 
Burst, is prima facie evidence upon which may be granted a decree of 
divorce of the parties contracting the first marriage. 

3. As evidence of a previous marriage from which the defendant 
has not been released by divorce or death, in proceedings to annul a 
subsequent marriage. 

4. As evidence of bigamy for the purpose of prosecution. 

5. As evidence of marriage in order that a widow may obtain her 
lawful share of her husband's estate. 

6. To prove legitimacy of heirs. 

7. As evidence upon which to correct the civil condition of the 
deceased in a record of death. 

8. As evidence of a widow's right to pension, under the Widows' 
and Orphans' Pension Act. 

9. As evidence upon w T hich a widow may obtain compensation for 
the death of her husband, as provided by the Workmen's Compensation 
Act. 

10. As evidence of the right of the widow of a soldier, sailor, police- 
man, or fireman to receive a pension from the federal or local 
government. 

11. As evidence upon which to change the record of birth of an 
illegitimate child. (It is customary in the Department of Health of 
the City of New r York, when the parents of an illegitimate child sub- 
sequently marry, to permit them to file a certificate of birth of such 
a child, from which it shall appear that the child is legitimate — as it 
becomes after the marriage of its parents under the provision of the 
Domestic Relations Act.) 

The average age at the time of first marriage has advanced during 
recent years, brought about by changing social and economic condi- 
tions, principally, the increased cost of living, the unwillingness of 
young people to assume the risks and obligations of married life 
without an assured income and the entrance of women into business 
and the professions. Nationality also exerts a very important influ- 
ence upon the marriage-rate and the age at the time of marriage. It 
is true, in the City of New York at least, that foreigners marry earlier 
than natives; that foreign men marry to a greater extent than native 
men. The marriage-rate is probably higher in cities than in rural 
communities because young folks are attracted to the city by the 
more numerous opportunities of employment and the higher wages 
procurable. Financial conditions have an important bearing upon 
the marriage-rate. Indeed, the marriage-rate is a very dependable 
index of prosperity; during the years of plenty it increases; during 
the years of hardship it declines. It is an interesting phenomenon 
that the marriage-rate declines during the years in which the presi- 
dential elections are held. 

The advance in the average age at the time of marriage, since it 
shortens the period of child-bearing, is responsible in a measure for 



CENSUSES . 813 

the decrease in the birth-rate which has occurred during late years 
in almost every civilized country in the world. 

Marriage statistics are secured by compelling clergymen, civil 
officials and other persons permitted by law to perform marriage 
ceremonies, to file reports of the marriages at which they officiate with 
the registration office. Many of the States have within recent years 
enacted marriage license laws, which require that all persons before 
being married must secure a license from a designated official, usually 
the city or town clerk. This license must be presented by the couple 
to be married to the officiating clergyman or official, whose duty it is 
to fill out that portion of the license which constitutes the certificate 
or report of marriage, and return the said license and completed cer- 
tificate to the city clerk. In some States, where a marriage license law 
has been enacted, no provision has been made for the ultimate filing of 
these records with the Department of Health, and since the law wisely 
did not repeal the original registration law, there is in certain cities 
a duplication of records, since the officiating clergyman or official is 
required to return the license to the city clerk and also to file a 
certificate of the marriage with the Department of Health. 

Methods of Calculating the Marriage Rate. — Marriage-rates may be 
expressed as the proportion of marriages to the total population, 
usually the number of marriages per thousand of the population. 
(The number of marriages, of course, is one-half the number of persons 
married.) This is known as the crude marriage-rate, and, like all 
crude rates is of value only as indicating the frequency of marriage 
in the same community from year to year. In other words, it cannot 
justly be used to compare the frequency of marriage in one community 
with the frequency in another community, because in probably no 
two communities are the number of persons at the marriageable ages 
the same, and in many communities, especially those recently settled, 
there is a preponderance of males as compared with females. 

The marriage-rate may be expressed as the number of marriages for 
each thousand of the population fifteen years and over. The most 
accurate method of stating the marriage-rate, however, is to state 
the rate in proportion to the number of unmarried, divorced and 
widowed persons of marriageable age, usually considered as over fifteen. 

Birth Statistics. — Birth statistics are of value because of the infor- 
mation they furnish for public health, legal and social purposes. 
From the viewpoint of public health, the use of birth statistics may be 
divided into statistical and administrative. To the statistician, birth 
records are of interest because the population is replenished by births — 
the growth of population being due in measure to the excess of births 
over deaths; because of the effect of the birth-rate upon the age 
distribution of the population; because the birth records contain 
information of the nationality of the parents, and, when used in 
conjunction with mortality statistics, enable the statistician to com- 
pare the infant mortality of different races. The statistician is 
further interested in birth statistics, because the most accurate method 
of stating the infant mortality-rate, is, in proportion to the number of 



SI 1 VITAL STATISTICS 

children horn, and it is evident that unless there is complete registra- 
tion of births, this method is faulty. 

The birth statistics furnish the sociologist with much interesting 
information; to particularize — the amount of illegitimacy, the fecun- 
dity of different races, the comparative fecundity of different classeSj 
etc. From an administrative standpoint, the health officer is inter- 
ested in birth records, because they are indispensable to infant welfare 
work, since they enable him to get in touch with the mothers within 
the first few weeks of their infants' lives, for the purpose of instructing 
and aiding them in the care of their offspring. 

Among the legal uses of birth records, the following are some of 
the more important: 

In Surrogates' Courts: 1. As proof of age and legitimacy of heirs. 
(This is probably one of the most important uses of birth records.) 

In Criminal Courts: 2. To determine whether a minor defendant 
shall be tried in the Childrens' Court or in General Sessions. 

3. As proof of age of the complainant in cases of rape. 

4. As proof of birth in bastardy proceedings. 

Birth records are also used for a number of purposes, as follows: 

1. Admission into the public schools. 

2. Obtainment of certificates of employment between fourteen and 
sixteen years of age. 

3. Proof of age for exclusion from provisions of selective service in 
the army or navy. 

4. Proof of dependency in claiming exemption from military service. 

5. Obtainment of passports. 

6. Obtainment of license to marry. 

Registration of Births. — In order that the birth statistics be of 
value registration must be complete. In the registration of births, 
the United States has been particularly backward. Even today, in 
many cities of the Union, little or no attention is paid to the registration 
of births. 

A short time ago the Federal Bureau of the Census established a 
registration area of births, to which were admitted all States in which 
registration reached 90 per cent, or over of all births occurring therein. 
In States that had not complete registration, cities with complete 
registration were admitted to the registration area. The usual pro- 
cedure in the registration of births is as follows: 

The attendant at birth — the physician or midwife — fills out a 
blank supplied by the Department of Health, and returns same to 
the local office. The local office either files the original and sends a 
copy to the central office, or files a copy and sends the original to the 
central office. In cities of the first class in New York State, original 
certificates of birth are filed at the local office and are not returned to 
the State Department. The Bureau of the Census, in consultation 
with the American Public Health Association, the . American Bar 
Association, and other similar organizations, had provided a model 
registration law which it urged separate States of the Union to adopt, 
not only that the States might have satisfactory registration laws. 



CENSUSES 815 

but that the latter might be uniform and the statistics prepared 
therefrom uniform and comparable. During the past several years, 
many of the States have adopted this law and the outlook for universal 
adoption throughout the Union is hopeful. The enactment, however, 
of a satisfactory registration law is but the first step in the collection 
of birth statistics. Completeness of birth statistics has suffered 
because of the little demand for official records of birth until recent 
years. 'With the development of practical uses of birth statistics, 
public interest in them was awakened. In the city of New York, the 
greatest impetus to complete registration of births was secured when 
the Board of Education found itself unable to house in the schools all 
the children who clamored for admission, and, in order to cut down 
the enrollment, necessitated that every child applying for admission 
present evidence that it was of school age. Since that time, other 
uses of statistics have still further increased interest in complete 
registration, and have aroused public opinion in support of the policy 
of strict enforcement of the registration law, with the punishment 
of offenders. Therefore, in order to secure complete registration of 
births in a community, the health officer should endeavor to awaken 
public interest in birth registration and arouse public opinion in 
support of his efforts to obtain complete registration, by finding 
practical uses for birth records. Having accomplished this much, he 
should lay down a policy of strict enforcement of the law and adhere 
to it without favoritism or prejudice. 

Method of Originating Complaints. — Complaints against physicians 
or midwives for failure to report births should originate in the central 
office, or in the State Bureau of Vital Statistics, in order that all 
possibility of favoritism and prejudice may be removed. Upon the 
receipt, by the local officer, the certificate of birth should be imme- 
diately stamped with the date of receipt. Upon its arrival at the 
central office, comparison of the date of birth with the date of receipt, 
will determine whether or not there is reason for complaint. After 
the complaint has been made, the offending physician or midwife 
should be given an opportunity to offer such excuse as they may 
have for their negligence. It will probably be better in the adminis- 
tration of the Department of Health to have the State Registrar, on 
certain days each month, visit certain localities in the State. It 
obviates the necessity of physicians visiting the Capitol, where the 
central office is usually located, with consequent expense and loss of 
time. In the city of New York, the policy of the Department of 
Health is to excuse first offenders, provided the certificates have been 
sent in voluntarily. In all cases where the negligence is discovered 
through the efforts of the Department of Health, for a first offense,, 
as well as subsequent, the offender is prosecuted. The law of the 
city of New York permits the Department to bring either civil or crim- 
inal action, or both, against an offender. The general procedure is 
to begin civil action, criminal action being reserved for the most 
chronic offenders. The corporation counsel of the city is authorized 
by statute to accept a fine where the defendant confesses judgment. 



816 



VITAL STATISTICS 



This procedure expedites matters and not only saves the Department 
the expense and trouble of taking all cases to court, but also saves the 
physician or midwife in a similar manner. 

A complaint or delinquent file should be maintained in the central 
office and record of every complaint made should be placed in the 
file. In this way, when preparing a complaint, a record of the 
offender's previous history can be readily obtained and a statement 
incorporated in the complaint for the guidance of the prosecuting 
official; when the complaint has been terminated, either by prosecu- 
tion and the imposition of a fine, or by the excuse of the offender the 
results should be entered upon the card for future reference. The 
following are some of the more useful methods of detecting violations 
of the birth registration law: 

1. Compare the reports of deaths of infants under one year of age 
with the birth register. 

2. Compare the enrollment of milk and infant welfare stations 
with the birth register. 

3. Compare the reports of communicable diseases among the children 
under tw T o years of age with the birth register. 

4. Secure the cooperation of district nurses and medical inspectors 
in detecting and reporting unreported births discovered on their daily 
rounds. 

5. Have the Health Department employes take censuses of children 
under one year of age in districts where the completeness of registra- 
tion is questioned. 

6. Compare birth notices in local press and new^s items referring 
to births with the birth register. 

7. Carry on publicity campaigns for the purpose of acquainting 
residents of the State with the great legal importance of a birth record, 
and the hardships unnecessarily brought upon a child, by the physi- 
cian, midwdfe or parents who neglect the important duty of recording 
a birth. 

8. Upon the receipt of a birth certificate send the physician an 
acknowledgment and the parents a neatly lithographed certificate, 
showing that their child's birth had been properly recorded. (It 
soon becomes common knowledge that the Department sends such 
certificate and parents learn to look for it when a child is born, and 
if one is not received, will inquire of the Health Department the 
reason that they have not received one.) 

Methods of Stating the Birth-rate. — There are several methods of 
stating the birth-rate: 

1. The crude rate is the number of births in proportion to the total 
population, usually stated as so many births per 1000 of the popula- 
tion. The rate is calculated by multiplying the number of births by 
" 1000" and dividing the product by the population. In a community 
having a population of 1,000,000, in which 30,000 births were reported 
during the year, the crude rate equals 30 per 1000: 



30,000 X 1,000 
1,000,000 



= 30 



CENSUSES 817 

2. The second method is to state the number of births in proportion 
to the number of women between the ages of fifteen and forty-five. 
This method is more accurate than the crude rate, but not as accurate 
as the third method, which is to state the number of legitimate births 
in proportion to the number of married females between the ages of 
fifteen and forty-five and the number of illegitimate births in propor- 
tion to the number of unmarried females between fifteen and forty-five 
years of age. 

The crude rate is of value in comparing the birth-rate of the same 
community from year to year. It is of a doubtful value when com- 
paring the birth-rate of different communities, for the very evident 
reason that the percentage of females especially of married females 
at the child-bearing ages in a community determines the birth-rate. 
The following are the factors which influence the crude birth-rate: 
The tendency throughout the civilized world to postpone the age of 
marriage, has been probably one of the most important factors in 
lowering the birth-rate. 

It is evident that the retardation of marriage shortens the period 
of child-bearing and therefore decreases the number of pregnancies. 
The next most important factor in the reduction of the birth-rate 
has been the prevention of conception by artificial means, which is 
practised by many people, who, either desire to entirely avoid the 
responsibilities of parentage, or who wish to control the size of their 
family. It is a well-known fact that among the foreign-born who 
take up their residence in this country and marry the birth-rate is 
several times higher than among the first and second generations of 
the same stock born in this country. 

The reduction of infant mortality has tended also to reduce the 
birth-rate, because, where infant mortality is high, children die within 
the early months of life, the mother ceases nursing and again becomes 
susceptible to impregnation; whereas, where the infant mortality is 
reduced and the child survives the period of lactation is prolonged 
and the chances of reimpregnation are lessened. A high birth-rate 
does not necessarily mean a prosperous or rapidly growing com- 
munity. On the contrary, in all countries where the birth-rate is 
high, infant mortality is also high, so that a high birth-rate may 
indicate nothing more than a waste of life, needless suffering and 
expense for nursing and prenatal care. 

The prevalence of venereal diseases, especially gonorrhea, is 
undoubtedly an important factor in reducing the birth-rate. A large 
percentage of the number of the cases of sterility, male and female, 
is due to gonorrhea. 

The above factors influence the birth-rate no matter how calcu- 
lated. The following factors affect the crude birth-rate: Financial 
conditions, as we have shown in a previous chapter on marriages, 
affects the marriage-rate and consequently, in turn, the birth-rate, as 
a high marriage-rate is usually succeeded by a high birth-rate and 
vice versa, during war the birth-rate declines because the men at 
52 



sis VITAL STATISTICS 

marriageable ages are on military duty; the termination of the war 
and the return of these men to the population are usually followed 
by an increase in the birth-rate; social position exerts an influence 
upon the birth-rate, through two factors which we have already men- 
tioned, i. c, the retardation of the age of marriage and birth control, 
and through the lowering of infant mortality, that is to say, that 
the persons in the higher social positions marry later. They are 
more apt to purposely regulate the size of their family. They are 
able, because of their better economic condition, to take better care 
of their children, and, hence, the mortality among their offspring is 
low, and in consequence, the birth-rate of people in the higher social 
spheres is lower. In other words, there is less waste of infant life. 
The birth-rate is usually higher .in cities than in country places, for 
the reason that young people are attracted to the cities by better 
opportunities of employment, higher wages, variety of amusement and 
social life, consequently, there is a larger proportion of persons at 
the marriageable and child-bearing ages in the city than in the country. 
Religion exerts an influence upon the birth-rate only inasmuch as it 
prohibits the limitation of offspring. It is noticeable that throughout 
the entire civilized world there has been a gradual decrease in the 
birth-rate extending over a number of years. If, however, a curve is 
plotted for the number of infants who survive the first year of life, 
this curve will take either an absolutely horizontal or an upward 
trend, so that while there are fewer children born today, a greater 
number reach womanhood and manhood, and, if mortality is reduced, 
it is reasonable to assume that morbidity among children is also 
reduced; in consequence there are few^er persons in the population with 
physical impairments left by the diseases of childhood than in former 
years, and we may say that there has been a progressive improvement 
in the health of the multitude. 

Professor Glover, in life tables which he recently prepared for the 
Bureau of the Census, conclusively showed that the natives of native 
parents, had a longer expectancy of life than did the foreign-born 
population in the United States, and this may well be attributed, in 
part at least, to the fact that the natives of native parents have avoided 
many of the diseases of childhood. 

Stillbirths. — Stillbirth statistics are of interest from the viewpoint 
of public health as well as from legal and social viewpoints. From 
the viewpoint of public health stillbirths cause useless suffering and 
are indicative of injurious environment or the presence of disease. 

Prom a social viewpoint, stillbirth statistics are of interest because 
of the waste of human life, because of expenditure of money for medi- 
cal care and Qiirsing of the mother and for the burial of the fetus. 
The causes of stillbirths are an index of the hazards of certain occupa- 
tions of the mothers during pregnancy. 

From a legal viewpoint, stillbirth statistics are of interest because 
demand i> made for production of these records in various civil and 
criminal court actions, 






CENSUSES 



819 



In many communities, not until after the fetus has reached the 
period of viability, usually the seventh month, are physicians and 
midwives required to report stillbirths. It is evident that the still- 
birth-rate in such communities is much lower than in communities 
where a stillbirth is defined "as the expulsion of the product of human 
conception at any time before full term." 

If stillbirth statistics are worth collecting, then there should be 
uniformity of procedure, and it is our belief that all stillbirths should 
be reported. The following is a copy of the stillbirth certificate in 
use in the city of New York and devised by the authors. It is prob- 
ably the most complete stillbirth certificate in use anywhere: 

DEPARTMENT OF HEALTH OF THE CITY OF NEW YORK. 
Bureau of Records. 
No fetus of any period of uterine gestation should be interred or disposed of in any other 
manner without a permit therefore having been obtained from the Department of Health, such 
permit to be granted upon the presentation of a proper return. 

Persons who are unable or unwilling for any reason to bury a fetus should immediately 
notify the Department of Health, which Department will see that the fetus is properly and promptly 
bured in the City Cemetery. 

Certificate of a Stillbirth. 

The death of an infant that has breathed must not be reported as a stillbirth; such cases 
must be reported by filing a certificate of birth and a certificate of death. 



Borough of . 



Registered No 

Character of premises, 
. St. whether tenement, private, 

hotel, hospital or other place, etc. 



Q§ 



75 Sex Color or Race Date of Stillbirth 191 



•— 'is 

aj 



E-e- fetus was 



(Month) 



(Day) 



Name 


Father 


Mother 


Residence 




Birthplace 




Age 


1 Color ! 1 Color 
! or Race! | or Race 




Occupation 


! 


Period of Number of 
Utero Gestation 1 | Previous Pregnancies 


J Number of | 
1 Living Births | 



I hereby certify that the foregoing particulars are correct as near as the same can be ascer- 
tained, and I further certify that I attended at this stillbirth; that the stillbirth occurred* on 
the day of 191. . ., that the actual cause of the death of this 



before 



H as 



and that said death of fetus occurre d ( j ur j n g labor 



Predisposing cause 

Witness my hand this. 
Filed 



.day of. 



191 



Signature. 
Address. . 



M.D. 



^ Place of Burial 



Date of Burial 



Undertaker 



Address 



(Reverse) 
Stillbirth Procedure for Midwives 
Should the child not breathe after birth, the midwife must report the fact at once, by telephone 
or messenger, to the Department of Health, when an inspector will visit the case and countersign 
the stillbirth certificate which the midwife must leave at the home. 

The fetus must not be removed from the premises until this certificate has been approved by 
the inspector from the Department of Health and a permit has been issued by the Bureau of Records. 



820 VITAL STATISTICS 

The causes of stillbirth arc many. Perhaps the most important is 
syphilis; other causes are too frequent pregnancy, previous miscar- 
riages, overwork of the mother during pregnancy, general febrile ill- 
ness, such as typhoid fever, pneumonia, etc. Labor is often induced 
prematurely to save the life of the mother, particularly when the 
mother is suffering from eclampsia, tuberculosis, heart disease, etc. 

Methods of Computing Stillbirth-rates. — The stillbirth-rate, may, 
like the birth-rate, be stated: (1) As the number of stillbirths in 
proportion to the total population; (2) as the number of stillbirths 
in proportion to the number of women at the child-bearing ages; (3) 
as the number of legitimate stillbirths in proportion to the number of 
married women in the child-bearing ages and the number of illegiti- 
mate stillbirths in proportion to the number of unmarried women at 
the child-bearing ages. Again, stillbirths may be stated as a percen- 
tage of the living births, or of the total number of births living and 
dead. 

In many communities it is the custom to include among stillbirths, 
the deaths of infants dying within the first few days of life. This 
custom is altogether blameworthy since it vitiates the statistics of 
stillbirth and infant mortality compiled in this manner. When the 
deaths of puerperal diseases are stated in proportion to the number 
of births reported, stillbirths should be included as well as living births. 

Deaths. — Mortality statistics are perhaps the most important of 
all vital statistics, and next to population statistics were the first 
to be collected, tabulated and studied. Mortality statistics are of 
importance from the public health, life-insurance, legal and social 
viewpoints. 

Since we shall devote most space to the discussion of the public 
health uses of mortality statistics, we shall clear the field by first stat- 
ing the legal and social uses of such statistics. The following are 
some of the more common legal uses of mortality records. 

/// the Surrogates' Courts: As evidence of death in probating a will. 

As evidence of death of a parent in applications for appointment 
of a guardian. 

As evidence of death of an heir. 

/// Civil Courts: As evidence of death in accident cases of which 
they form the basis of action. 

To explain the non-appearance of a witness whose testimony is 
required in any civil action. 

In Criminal Courts: As evidence of death of a defendant in order 
to secure tin 4 discbarge of the bondsman who has given bail for his 
appearance. 

As evidence of death in order to have indictment against deceased 
dismissed. 

Miscellaneous Uses: As evidence upon which to collect insurance 
upon the life of the deceased. 

As evidence of the cause of death in order to collect accident insur- 
ance on the life of the deceased. 






CENSUSES 821 

As evidence of death of a beneficiary of a life insurance policy. 

As evidence upon which to collect bank deposits of deceased persons. 

As evidence of death of a subject ordered to report for military 
duty by those foreign governments which compel all their male subjects 
to perform military duty. 

As evidence of death in applications to the Police Department to 
remove a picture of a deceased person from the rogues' gallery. 

As evidence of death to be submitted to a city or governmental 
department, which has been paying pension to the deceased. 

As evidence of death to be submitted to the Workmen's Compen- 
sation Commission. 

As evidence of death of civil or other pensioners, in order that their 
widow or other dependents may be granted one, in lieu of that paid 
to the deceased. 

Evidence upon which to secure widows' and orphans' pensions. 

As evidence of death of an illegitimate child, in order that the 
father may be released from further payments for its care. 

Mortality Statistics. — From an actuarial standpoint, mortality statis- 
tics are of importance, because they are the very foundation upon 
which life insurance is built. Without mortality statistics scientific 
life insurance would be impossible. 

Death statistics are of value from a social point of view, because 
of the information they give of the social life of the people. 

From the viewpoint of public health, death statistics are of impor- 
tance, because they form the most reliable index of the health of a 
community. They are also of interest because of the light they shed 
upon the importance of different diseases and because they serve as 
an index of the success that has attended human efforts to reduce 
illness and prolong life. From an administrative point of view, 
death statistics are of value in public health work, because the report- 
ing of deaths enables the health officer to investigate the causes of 
death and to take such action as may be necessary to control the 
spread of communicable diseases. 

Death-rates. — A death-rate is the ratio between the number of 
deaths and the number of persons in the population. It is generally 
expressed in terms of the number of deaths per 1000, 10,000, 100,000 
or 1,000,000 of the population. 

The term crude or general death-rate is applied to the ratio between 
the number of deaths annually per 1000 of the population and is 
obtained by dividing the number of deaths by the number of thousands 
in the population as, for instance, if there were 1200 deaths in the 
year 1917 in a city with a population of 100,000 the crude death-rate 
would be 12 per 1000, obtained by dividing the number of thousands 
in this instance 100, into the number of deaths. In the city of New 
York, in 1917, there were 78,575 deaths reported in an estimated 
population of 5,737,492, the manner of obtaining the rate being 
expressed thus: 78.575 -5- 5,737,492 = 13.70. 



822 



VITAL STATISTICS 



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Florence 
Genoa 
Glasgow . 
Lyons 

Manchester . 
Marseilles 
Milan 
Paris . 

Stockholm . 
Zurich 






CENSUSES 823 

The crude rate of a city, State or country is used chiefly in com- 
parisons with the crude rates of previous years and may be used in 
comparisons with rates of other cities, States or countries provided 
the sex and age constitution are approximately the same. If there be 
a decided difference in the sex and age grouping of localities or com- 
munities whose death-rates are to be compared, there should be 
allowance made for this dissimilarity by a standardization of the 
rates. This procedure is explained in the appendix to this chapter. 

The table on page 822 gives in the third column the crude death- 
rates of certain foreign cities and the city of New York for the vear 
1917. 

Crude Death-rates. — The extreme variation between the crude 
rates of the various cities is exemplified in the rate of 10.44 for the 
city of Zurich and 25.82 in the city of Barcelona. Of course it is 
understood that the crude death-rate of a city or country is not by 
any means an accurate yard stick to measure the comparative mor- 
tality among cities or countries, as the factors of sex and age distribu- 
tion play a most important part in determining the crude death-rate 
of a community. Nevertheless, it is fair to assume that the age 
constitution of the cities mentioned in the table is not so widely 
variant as to explain the striking contrast between some of the rates. 
Another difficulty that presents itself is the inability to make allow- 
ances for the departure of the soldiers and sailors to the seat of war 
from many of the cities mentioned in the table and for the failure of 
the officials to divide the deaths into the two groups of civilians and 
returned soldiers. This latter factor might possibly be considered a 
negligible one as most of the deaths among the armed forces took 
place in battle or in hospitals situated at or near the front or at least 
outside of the area of the cities specified. 

Weekly Death-rates. — A weekly death-rate expresses the number 
of persons who would die yearly provided the same number of persons 
died every week as died in the week under consideration. If 100 per- 
sons died in a city in the week of October 26, 1918, and the estimated 
mid-year population was 400,000 then the sum would be expressed as 
follows : 



No. of deaths. 




No. of weeks 
in a year. 


No. of thousands 
in population. 


No. dying of every 
1000 of population. 


100 


X 


52.17747 


-T- 400,000 


13.04 



Monthly Death-rates. — As the number of days in each month is 
not a constant factor it is necessary in order to obtain correct rates 
to make allowance for the number of days in each month in preparing 
monthly rates. In the month of September, 1918, in the city of 
New York there were 5013 deaths reported, the rate for the month 
being calculated as follows: 

Estimated population. No. of deaths. No. of months in year. 

365.24 ,„„ ,„ JX 
5,837,143 5013 3Q (12.174) 



824 



VITAL STATISTICS 





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826 



VITAL STATISTICS 



Multiply the number of deaths, 5013, by the factor obtained by 
dividing the number of days in the month, 30, into the number of 
days in the year, 365.24 (12.174), and divide the product by the 
number of thousands in the population, 5837.143. The resulting 
quotient will be 10.45 which is the death-rate per 1000 of the popu- 
lation for the month, and is to be interpreted to mean that if 5013 
deaths occurred in every month having thirty days the annual rate 
would be 10.45 per 1000 of population. 

Quarterly Death-rates. — Quarterly death-rates are prepared in 
similar manner to the weekly and monthly rates with the exception 
that the multiplying factor is different; if there are ninety days in 
the quarter then the factor will be the quotient arising from the divisor 
of the number of days in the year, 365.24 by the number of days in 
the quarters, 90, i. e., 4.058. 

Specific Death-rates. — In addition to the crude death-rates it is 
necessary to prepare death-rates of certain prominent causes of death 
in order to measure the effect of preventive action by public health 
officials. In preparing rates based on individual causes of death the 
procedure is the same as stated above. The table on pages 824 and 825 
gives the death-rates from all causes and from several principal causes in 
the city of New York for a period of twenty years. As the age con- 
stitution of the population of the city has changed only slightly during 
that period the rates are comparable without criticism. 

It is of importance upon occasion to prepare death-rates based 
upon age groupings of the population, especially at the age group 
under one year and that under five years; the table gives an example 
of this specific rate in the death-rates of children under five years 
from diarrheal diseases, and in the rates under one year of age from 
all causes. In order to calculate the death-rates at any certain age 
group the procedure is to ascertain the percentage of the age group to 
the whole population as given in the census reports and to apply this 
percentage to the estimated population for the year desired; for 
example, the entire population of a city by the census returns in 1910 
was 220,000 and the number of children under five years was 22,000, 
which is equivalent to 10 per cent, of the population; if it is desired to 
know the number of children in the year 1917, and the estimated 
population was 260,000 in that year then 10 per cent, of 260,000 or 
26,000 would be the estimated number of children living at that year; 
if the annual number of deaths among children under five years of age 
was 1440, then by dividing the number of deaths by the number of 
thousands in the estimated population of the age group the quotient 
will be 55, i. e., 55 children out of every 1000 living at that age group 
died during the year. 

Factors that Meet the Death-rate. — The Effect of Sex on Mortality. — 
In nearly all civilized countries there has been recorded year by year 
a much lower death-rate among females as compared with males; in 
the registration area of the United States the rate has been lower for 
each year irrespective of race or color. The difference has averaged 



CENSUSES 82* 

for many years about two more deaths per 1000 of the population 
among males. The higher mortality among the males exists at 
every age group of the population. 

In communities in which the proportion of females to males is higher, 
such as health resorts in which large numbers of female servants are 
employed, the effect of lowering the mortality-rates is considerable. 
The increased mortality among males is due to several causes, such as 
hazardous occupations, abuse of intoxicating liquors and suicide. 

The Effect of Age on Mortality. — The mortality at the extremes of 
life is much greater than at the intervening periods, roughly speaking, 
descending from 100 deaths per 1000 living under the first year of 
life, to a rate of 2 per 1000 at about the eleventh year of life and 
gradually increasing until at the seventy-seventh year the rate experi- 
enced under the first year of life is duplicated. 

A community of recent growth, such as a "boom city" of the West, 
will contain a large percentage of individuals at ages between twenty 
and forty-five years, at which ages death-rates are low, with the effect 
that a crude death-rate results which is much below those of the 
eastern cities. Seattle, St. Paul and other large cities of the West 
have a death-rate as low as 9 or 10 per 1000 of the population, as 
against rates in New York, Boston and Philadelphia of 14 to 16 per 
1000. The latter cities spend millions upon conservation of health 
of the communities, the former spend comparatively little, and the 
unthinking accept without question the printed statements that are 
circulated in reports of boards of trade that the city they represent 
has the lowest death rate or next to the lowest of any city in the United 
States. The low death-rates in these cities are due in great measure 
if not entirely to the favorable age grouping of the population, which 
makes for a low death-rate irrespective of surrounding health 
conditions. 

Race and Nationality. — The mortality of the negro is far heavier than 
that of the whites. In the city of New York in 1916 the death-rate 
of the whites was 13.7, the colored rate 24.4, and this despite the 
fact that the colored population had a more favorable age distribution. 
The table on page 832, taken from the 1916 Annual Report of the 
Department of Health, clearly shows the excessive mortality among 
the negroes at all age groups. 

The mortality of the different nationalities also varies, but not to 
the extent that the negro mortality varies from the white mortality. 
Prof. Glover, in the life tables prepared under his supervision for 
the Bureau of the Census, shows that the native-born have a lower 
mortality and a higher expectancy of life than have the foreign-born 
residents of the United States. 

Marital Condition. — The death-rate among married males at age 
groups over twenty years is much lower than among single, widowed 
or divorced males. The death-rate among married females is slightly 
higher at the age group twenty to forty years than among single females 
— due probably to the deaths from puerperal causes among the married 



828 VITAL STATISTICS 

but is much lower at this and other age groups than the widowed or 
divorced. 

Density of Population— This, in itself, has little effect upon mor- 
tality; where the population is densely congested other conditions are 
usually unfavorable, as there is poverty, ignorance and dirt. The 
number of persons occupying a room is a far more important factor 
than the number of persons per acre. The room density has a very 
direct influence upon the prevalence of the acute infectious diseases. 

Sanitation. — The sanitary conditions of a community, for obvious 
reasons, has a very direct influence upon the health and mortality of 
the residents. Where the sewage disposal is inadequate, where the 
water system is not properly guarded, where the handling of milk is 
not supervised, such diseases as typhoid and other intestinal diseases 
are prevalent. 

Economic Conditions. — Within recent years we have come to realize 
that economic conditions exert a most important influence upon 
mortality. Where the family income is small, housing is poor, food is 
of poor quality and often insufficient in amount and proper medical 
care is lacking. In fact we realize today that the family income 
has a most direct bearing upon the family's health, both mental and 
physical; the amount of family income determines the character of 
the premises in which they live, the quantity and quality of their food, 
the sufficiency or insufficiency of their clothing, the enjoyment of 
wholesome pleasures, and other factors that determine the condition 
of health. Likewise, the worker's earnings determine whether he 
shall be able to accumulate sufficient savings to care for himself in the 
e\ent of illness ancl to provide for his old age. 

1 1 ox]) it al and Clinic Facilities. — The presence or absence of sufficient 
hospitals and clinics to care for the poor who are ill naturally has a 
most important influence upon the death-rate of a community. In 
large centers of population hospitals and clinics are indispensable, not 
only for the treatment of general surgical and medical cases, but for the 
isolation and treatment of persons suffering from acute contagious 
diseases. The provision of adequate facilities for caring for persons 
suffering from tuberculosis is also important. To a lesser degree, 
the provision of district nurses, social service, etc., affects the health 
of a community and consequently its mortality. 

Occupation. — Occupation has a most important bearing upon 
mortality. There are certain occupations which, because of their 
inherent hazards, cause high rates of mortality among the persons 
engaged in them. In studying the relation of occupation to mor- 
tality, one must not lose sight of the influence of age distribution upon 
mortality. We need only consider the matter for a moment to realize 
that the ages of persons employed in different occupations vary within 
wide limits — e. (/., bankers, clergymen, professional men — have a 
higher average age than persons engaged in occupations that require 
shorter periods of preparation. Again, other occupations, because of 
the environment or less arduous duties, attract persons of advanced 



CENSUSES 829 

ages. An example of the effect of age upon the mortality of occupa- 
tion, is clearly shown in a study of the mortality of farmers. It will 
be found that the crude death-rate of farmers is far above the average 
for the country as a whole. But, if the mortality of the farmers is 
corrected for age distribution, they will be found to have a mortality 
below the average of the country. The determining factor of the 
high mortality among farmers is their advanced ages. 

■Birth-rate. — The birth-rate of a community affects its death-rate in 
the following manner: If the number of births equal the number of 
deaths, we have a so-called stationary population, in which the birth- 
rate has little influence upon the death-rate. If in such a community 
the birth-rate, for any reason whatsoever, increases so that it exceeds 
the death-rate, then during the first ten years the death-rate in that 
community will also be increased, because the population at the 
beginning of life when mortality is high has been increased. If, 
however, the high birth-rate continues during the next ten years, 
those children that have survived the first ten years of life, will have 
entered upon a ten-year period during which mortality is at its lowest, 
and the crude death-rate will consequently fall. If the birth-rate 
continues to exceed the death-rate, the death-rate will be forced still 
lower because a large number of persons are brought nto the popula- 
tion, who, as they reach the ages of low mortality, say from ten to 
forty years of age, tend to reduce the crude death-rate. If after a high 
birth-rate for ten years, the birth-rate again falls to its former height, 
the death-rate will be abnormally low because the children born during 
the ten years will have entered upon a period of low mortality, and 
as fewer children are born there will be fewer in the first ten years of 
life when the mortality is high. When the children born during the 
ten years when the birth-rate was high, enter the third decade of 
life, the death-rate will again commence to rise until it exceeds its 
former height. 

Migration. — Immigration and emigration affect the mortality of a 
community by reason of then effect upon age distribution. Persons 
who migrate are usually young adults. In other words, persons who 
are in that period of life when the mortality is low. Therefore, it 
follows that if such persons emigrate from a community, the death- 
rate of that community will rise in proportion to the number of persons 
who emigrate, and it also follows that immigration for the opposite 
reason, that is, because it increases the number of persons in the 
population at the ages of low mortality, decreases the death-rate. 

Non-residents. — In many communities, the non-residents exert an 
important influence upon the mortality. This is especially true in 
health resorts to which the ill flock and whose deaths are then counted 
against the community. In winter and summer resorts the deaths 
are included in the mortality of the community while they are not 
included among the population. In large business centers the mor- 
tality among visitors tends to raise the mortality of the community. 
The' mortality among inmates of hospitals and other institutions 



830 VITAL STATISTICS 

increase the mortality of the community in which the hospital or insti- 
tution is located if the district from which the patients are recruited 
extends beyond the boundaries of the community itself, as is fre- 
quently the case in State hospitals, institutions for the insane, sani- 
toria for the treatment of tuberculosis and colonies for alcoholics and 
epileptics. Similarly, private institutions, because of their reputa- 
tion for the successful treatment of certain diseases, attract large 
numbers of patients from other communities. 

The problem of treating deaths of non-residents is a rather difficult 
one, and will only he satisfactorily solved when there is a nation-wide 
system of exchange of non-resident deaths whereby the deaths in. 
one community of residents of another community will be charged 
back to the community wherein the deceased had their usual or legal 
residence. 

In the city of New York the custom is to include in the mortality 
of the city the deaths of all non-residents. Those who die of accidents 
met with in the city, and of acute diseases contracted since residence 
in the city began, such as lobar pneumonia and the acute infectious 
diseases, are properly included in the death lists; while the deaths of 
non-residents caused by chronic conditions, the duration of which 
was greater than the length of residence, might with propriety be 
excluded from the mortality of the city in the event of a correction 
being made of the death-rate for this factor. 

Infantile Mortality. — Infant mortality is probably one of the most 
important subjects in the entire field of vital statistics: (1) Because 
children born into the world replenish the population depleted by 
death; (2) because from the infants are recruited the citizens of the 
next generation, and as their mortality is an index of their morbidity 
it stands to reason that if morbidity is high among infants their 
resistance to attacks of disease in the future will be lessened and they 
will enter upon life with a serious physical and perhaps mental handi- 
cap. Infant mortality is of further importance because it is a most 
reliable index of the sanitary conditions of a community and the 
progressiveness of its health work, and when the infant mortality-rate 
is computed upon the number of living births reported during the 
year, it is, if registration of births is complete, an absolute index of 
conditions because the rate is not affected by the distance in time of 
the year under consideration from the census year; in other words, 
the infant death-rate is computed upon an accurate enumeration of 
the infant population and not upon an estimate. 

In the discussion of the errors in the census enumeration, we called 
attention to the fact that the enumeration of infants under one year of 
age at a census was almost always inaccurate because of the tendency 
of parents and others to state the age of infants under one year of age 
as one year. For this reason it is inadvisable to compute an infant 
mortality-rate upon the population under one year as determined at 
a census; if based on this latter it will serve only as an approximation 
of the true infant mortality-rate. 



CENSUSES 831 

Factors which Affect Infant Mortality. — Prenatal Conditions. — (a) 
The conditions under which the mother lives during her pregnancy 
have been shown conclusively to affect the health and vitality of her 
child and frequently cause premature birth. We refer particularly 
to factory employment, undernourishment and poverty, (b) Diseases 
of the parents such as syphilis, tuberculosis, epilepsy and alcoholism. 

Postnatal Co nditions.— Ignorance of the parents as to the proper 
care of infants. Industrial and economic conditions which necessitate 
the mother working during the period of lactation, thereby depriving 
the child of its mother's undivided attention and creating the necessity 
of partially or completely feeding the infant artificially and of entrust- 
ing their care to inexperienced children and neighbors. 

Poverty. — Which necessitates an unwholesome environment and 
which makes for insufficient and improper food for the mother during 
pregnancy and lactation and for the child after the period of lactation. 

Overcrowding. — Overcrowding itself has little effect upon infant 
mortality. If the buildings are up to date, sanitary conditions good, 
rooms light, facilities for cleanliness sufficient, there is no reason why 
overcrowding, unless, carried to an extreme degree, should have any 
effect on infant mortality except upon incidence and mortality of the 
acute contagious diseases. It is conceivable that where a number of 
persons are living in close contact the possibility of spreading acute 
contagious diseases is increased in proportion to the degree of over- 
crowding. 

Social Conditions. — Which at present cause mothers to artificially 
feed their young in order that they may devote more time to social 
functions and the pursuit of amusement. In this connection it is 
interesting to note that the death-rate of infants of native mothers in 
moderately comfortable financial circumstances is higher than among 
the uneducated and very poor foreigners who nurse their young. 

Overage and Underage of Parents. — When the parents are either too 
young or too old the vitality of their offspring is usually low. 

Illegitimacy. — The death-rate of illegitimate infants is from two 
to four-fold that of children born in wedlock, and is due to the diffi- 
culty surrounding their gestation and birth and the tendency, if 
indeed not the necessity, of entrusting them to foundling asylums. 

High Infant Death-rate.— In countries where the birth-rate is high, 
the infant death-rate is usually correspondingly high, but the high 
mortality is rather the cause than the effect since the death of an 
infant shortens the period of its mother's lactation and predisposes to 
immediate reimpregnation; frequent impregnation lowers the vitality 
of the mother and forms a " vicious circle." 

Immediate Causes of Infant Deaths.— The immediate causes of 
infant deaths are: (1) Respiratory diseases, bronchitis and pneu- 
monia. The mortality of these diseases is greatest during the winter 
months, and is particularly high among the Italians and negroes, and 
is usually greater in the colder than in the warmer climates. (2) 
Diarrheal diseases, the mortality of which is high during the summer 



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t>" co" to" i>" cm" lo" co" io" co" 

COCM<-i 


X 


.2 

"3 

2 

43 
fa 


t^ 


OcDC5iCl>CMcDOC5 

xoxmt^coococo 

O CM_C CM "* CM t- O O 

■*" co" co" ■*" x" co" co" co" cm" 


o 

OS 
CM 

x" 
»o 


DO 

"3 


co 


comt»CMior^Tt<t^co 

—iCMCMCM!>CO-*CMCO 
X X CO -H o_t>. CO i-O CO 
CO" CM* CM" CO" Tf" cm" co" cm" i-" 


§ 

iO 

o" 


6 


C X 

QQ ° 


t.O 

§ 

CO 


587,900 
508,650 
490,500 
530,300 
1,174,450 
916,300 
648,120 
362,570 
265,770 


CM 

C5 

o 
x" 

X 

■<* 

IO 


3 

- 


2 

CO* 

eo 


291,600 

253,750 
245,000 

279, SOU 
599,950 
442,200 
306,950 
178,200 
142,840 


CM 

O 
CO 

eo" 
cm" 


9 


- 
© 

© 

X* 

© 


296,300 
254,900 
245,000 
250,500 
577,500 
474,100 
331,170 
184,370 
122,930 


§ 

CM* 




a 


i 


03 

-a 
a 
P 


Under 5 
5 to 9 
10 t0 14 
15 to 19 
20 to 29 
30 to 39 
40 to 49 
50 to 59 
60 and over 


"o 

H 



CENSUSES 833 

months, and among bottle-fed infants. (3) Congenital diseases and 
malformation— the mortality from these diseases has changed but 
little in the past, whereas the mortality of the other diseases of infancy 
have been gradually forced downward. The table on page 832, taken 
from the yearly report of the New York City Health Department, 
graphically presents this fact. The death-rate from the congenital dis- 
eases is highest among the negroes and among the children of native 
white mothers. The contagious diseases play but a relatively unimpor- 
tant- part in infant mortality during the first six months; after the 
sixth month susceptibility to these diseases increases rapidly. There 
is a direct relation between room overcrowding and the incidence and 
mortality of these diseases. (4) Syphilis per se causes but compara- 
tively few deaths of infants. It, however, gives rise to a multitude of 
ills and renders infants susceptible to the other diseases of childhood. 
The mortality of syphilis is probably purposely hidden by physicians 
who report deaths of infants from this cause as prematurity, marasmus 
and inanition. 

During the past fifteen or twenty years the death-rate among infants 
has been reduced more than half in New York City. In a great 
measure the reduction has offset the decline in the births, so that 
despite the fact that fewer babies are born now than fifteen or twenty 
years ago, the proportion of infants that survive the first year of life 
is approximately the same as formerly. The infant welfare work 
that has been carried on during this time has resulted in the mainten- 
ance of the same number of infants at one year of age from a much 
smaller number of children born; and it is reasonable to suppose that 
the infants today who reach the first year of life are healthier and 
stronger and enter upon the remainder of their lives with fewer physical 
handicaps than did the first-year survivors of fifteen years ago. 

Registration. — The first record that we have of compulsory regis- 
tration was in Rome about the time of Servius Tullius. The purpose 
of this registration is not disclosed. In England the office of the 
Registrar-General was established in 1836, and registration by the 
civil authorities began as a result of an Act of Parliament on July 1, 
1837. In this country the first dependable statistics of deaths were 
collected in Massachusetts and in New Jersey. In the city of New 
York the first mortality returns were made in 1795 and consisted of 
a list of the persons who died during an epidemic of yellow fever in 
that year. 

Registration of deaths began in the city of New York in 1798, and 
with the exception of a few years in the first decade of the nineteenth 
century has continued down to the present day. In the early days 
the registration was not complete for the reason that there was no 
satisfactory system of issuing permits for burial. The following is 
an extract from the report of the Metropolitan Board of Health in 
1866: 

"The registration of deaths in New York City dates back to the 
year 1803. Cemetery records and the return of certificates of death, 
53 



834 



VITAL STATISTICS 



through the cemetery keeper or sexton, until within the last twenty- 
three years, supplied the information of deaths to the City Inspector. 
Until the adoption of new regulations last spring serious irregularities 
prevailed. The frequent application for transcripts of death records 
which had never been registered led to inquiries that confirmed and 
solved the question of incompleteness in the public registry. The 
Metropolitan Board of Health has heartily sustained its Bureau of 
Vital Statistics in maintaining that 'considered physically, the main 
object of a correct civil registration of births, deaths, marriages is to 
aid in disclosing the causes of disease; that considered legally, the 
object is to provide means of tracing descent and proving personal 
identity, and that considered politically, it is to assist the government 
in arriving at correct conclusions with regard to measures of internal 
economy, employment, etc.'" 

So that it was not until a demand for transcripts of death records 
brought home to the authorities the incompleteness of registration 
that steps were taken to secure a record of every death that occurred in 
the city. The following quotation, also from the Metropolitan Report 
of 1866, is of sufficient interest to quote: 

"In no other city in the world did greater need of such systematic 
and rigid rules exist. I am happy to state that no opposition has been 
shown to this rigorous system, though until the Metropolitan Sanitary 
Board ordered it into operation, the city inspectors' permits were to 
be had for the asking — ready signed and in quantity — at the shops 
of various undertakers and medicine vendors in different sections of 
New York City. Such a premium on the daily violation of the statute 
regarding the interment and the sanctity of human remains was not to 
be tolerated. A Board of Health and its Bureau of Vital Statistics 
could not allow that vicious system to continue for an hour. The 
Metropolitan police quickly gathered up and brought to headquarters 
all those unguarded burial permits. There were other and very 
gross evils connected with the custody and registration of the dead, 
which were promptly corrected." 

Until a permanent Federal Bureau of the Census was established 
the only means that the federal government had of securing mortality 
statistics was by incorporating in the census a query as to the names, 
ages, civil conditions, etc., of persons who had died in each household 
during the year prior to the last census. It is apparent that such a 
method of collecting mortality statistics w T as almost useless because 
of the tendency of persons to fail through forgetfulness or design to 
report to the enumerators deaths in their household. Usually, upon 
the death of the head of the family, the household broke up and the 
members then living apart, each reported the death of the head of 
the family thus causing the duplication of records, or each depending 
upon some other member of the family to report the death omitted to 
report, thus causing incompleteness. 

Registration Area.— The Federal Bureau of the Census established 
in 1880 a registration area to which States and cities in which registra- 






CENSUSES 835 

tion of deaths was approximately complete were admitted. Certifi- 
cates of death filed in the registration area were copied by persons 
in the employ of the Federal Bureau and forwarded to the Central 
Office in Washington for tabulation. The following paragraph, taken 
from the published report of the ninth census, 1870, is of interest: 

"The dimensions attained by the life insurance institutions within 
the past few years make it peculiarly a matter of regret at the present 
time that the census should not afford the data for determining with 
absolute precision and certainty the death-rate of the country, whether 
in the aggregate or by classes of population. This can only be done 
by national scheme of registration, stringently enforced by penalties." 

Dr. Cressy L. Wilbur, formerly Chief Statistician, Division of Vital 
Statistics, Bureau of the Census, deserves unstinted praise for the 
progress made in the United States toward accurate and complete 
registration of deaths. He was untiring in his efforts and the success 
that he had will ever remain a monument to his memory. 

Method of Collecting Mortality Statistics. — The source of the 
statistical data of death is obtained from the reports filed by physi- 
cians with the statistical office. These reports, known as certificates 
of death, call for information as to the name of the disease, place of 
death, sex, age, color, civil condition, occupation, birthplace, parents' 
names and birthplaces, cause of death, usual address and in the 
majority of cases, duration of residence at the place of death, and if 
foreign-born, duration of residence in the country. Model certificates 
have been prepared by the Bureau of the Census and adopted by the 
States and cities in the registration area. 

As we have seen in the early registration of deaths in Xew York 
City, registration was incomplete until provision was made in the 
law that no human remains be disposed of without a permit issued 
by an authorized representative of the Department of Health. The 
usual procedure in Xew York City is as follows: The physician is 
allowed thirty-six hours to file a proper certificate with the authorities. 
In cases of acute infectious diseases certificates must be filed imme- 
diately. 

Upon the death of a patient the physician in attendance fills out 
and files with the Department of Health a certificate of death. The 
undertaker applies to the Department of Health for permit for burial, 
and upon the presentation of satisfactory evidence that he has been 
engaged by the relatives of the deceased a permit for burial or crema- 
tion is granted. The permit specifies the cemetery or crematory and 
the date of burial or cremation accompanies the remains of the deceased 
to the place of burial or cremation to be surrendered to the person in 
charge of the crematory or cemetery. Within a specified time after 
burial or cremation the superintendent of the cemetery or crematory 
is required to return all permits received since the date in which he 
made his last return to the office of the Bureau of Records of the 
locality in which the crematory or cemetery is located. At the present 
time there is no system of clearing returned permits by the different 



836 VITAL statistics 

cities and States. While such a nation-wide system would entail 
considerable expense there is no doubt that it would be of value. 
Where permits have been altered or in cases where they are not 
returned investigations are made and if the evidence justifies it 
complaints against the keepers of the cemeteries or crematories are 
forwarded to the corporation counsel for prosecution. 

Causes of Error in Data Contained in Certificates of Death. — 
Physicians in order to have the privilege of signing death certificates 
must be duly licensed and are required to register their signatures with 
the burial permit office of the local Bureau of Vital Statistics, that is, 
the Bureau of Vital Statistics in the locality where they intend to 
practice. The purpose of such registration is to enable the health 
officer or his representative to verify the signature of the physician 
upon every certificate of death submitted for the purpose of obtaining 
a burial permit. The importance of this requirement is so apparent 
that it need not be further discussed. 

Certificates of death should be filled out in toto by the attending 
physician. If undertakers are permitted to fill out certificates in so 
far as they relate to the personal and family history of the deceased, 
there is the temptation in cases where this information is difficult to 
obtain to substitute fictitious data. The law should provide a penalty 
for wilfully filing false reports. Unintentional errors are frequently 
made in certificates of death, especially in cases where the physician 
is compelled to obtain the information from someone not closely 
associated with the deceased. 

From a statistical standpoint the data of the occupation of the 
deceased contained in certificates of death is not always reliable. 
There are many reasons for this; perhaps the most important one is 
that the importance of this information has not been fully realized 
by health officers, and they in consequence have not insisted upon a 
specific statement of the occupation of the deceased. Another fre- 
quent cause is that in death certificates of old persons who retired 
from active employment prior to death no occupation is given. Never- 
theless, the effect of their occupation prior to retirement may have 
had an important bearing upon their last illness. Again, occupation 
may be stated in such a way that it throws very little light upon the 
hazards to which the deceased was subjected. Still, again, there are 
persons who prior to death suffered from a chronic disease, such as 
pulmonary tuberculosis, and were compelled because of their illness 
to give up their usual occupation and seek one less arduous. It is 
evident in such cases that the last occupation of the deceased had 
little or no bearing upon the cause of death, whereas the usual occu- 
pation may have been an important factor in the etiology of the 
(lipase that caused death. In order to overcome as far as possible 
these shortcomings in the statement of occupations of deceased 
persons the model certificate of death calls for the particular kind 
of work the deceased performed, as well as a specific statement of the 
industry in which the deceased was employed. 



CENSUSES 837 

The cause, of death is at times unreliable. In coroners' cases where 
autopsies have not been performed the importance of making post- 
mortem diagnosis without autopsy is apparent, especially in those 
cases in which a satisfactory history is not obtainable. There are 
many cases in which even expert clinicians are unable during the life 
of the patient to correctly diagnose the cause of illness. There is, 
therefore, in all cases where diagnoses are based upon clinical findings, 
a percentage of error. Recently several pathologists have endeavored 
to show the unreliability of mortality statistics by comparing clinical 
diagnoses with autopsy findings. At first glance these studies create 
apparently a well-founded doubt as to the usefulness of mortality 
statistics based upon death returns, but if we bear in mind the fact 
that certain diseases are and have been for many years possible of 
positive diagnosis, as for example, many of the acute infectious dis- 
eases, that the physical signs of other diseases are unmistakable, and 
that in still other diseases bacteriological and other laboratory exami- 
nations are frequently employed as aids to diagnosis of the causes 
of death, we can take a more optimistic view of the situation and 
feel that after all mortality statistics are, on the whole, dependable. 
Furthermore, it is a w.ell-known fact among statisticians that in 
dealing with large numbers errors tend to correct themselves. That 
is to say, that if a certain percentage of errors are made in diagnosing 
one disease as another, a similar percentage of errors will be made 
conversely. 

Recently a committee of the American Public Health Association 
examined the causes of death given in the International Classification 
of Diseases and Causes of Death with the purpose of determining 
what diagnoses should be accepted as reliable without autopsy, and 
those that should be accepted as reliable only after autopsy. It 
was proposed in addition to the routine tabulations that a tabulation 
be made in which the reliable and unreliable diagnosis should be 
separated. The practicability of this scheme, however, is question- 
able at present. In the first place, it will be years before sufficient 
data will have been accumulated for comparison. In the second 
place, there are numerous practical difficulties that will be encountered 
and must be satisfactorily solved, e. g., the committee decided that 
valvular heart-disease was a diagnosis that may be accepted without 
autopsy, but it is evident if this diagnosis is returned by coroner's 
physician or a medical examiner without autopsy and without a state- 
ment from a physician who had examined the deceased during life 
and made such a diagnosis then this assignment would be absolutely 
valueless, and could not be placed among the reliable causes of death ; 
in the third place the difficulty in obtaining a unanimity of action by 
local registrars. 

Much valuable additional data as to the cause of death can be 
obtained by directing letters of inquiry to physicians reporting unsat- 
isfactory causes of death, as for example, where the cause of death is 
returned as apoplexy without underlying cause or cancer without a 
statement of the location. 



838 



VITAL STATISTICS 



The following is the form letter which in the city of New York is 
sent physicians who in their reports of deaths fail to give sufficient 
information for statistical purposes: 



Ckrtificate No. 



BUREAU OF RECORDS. 

New York 192 

Dbab Doctor: 

Will you kindly forward to this office, at your earliest convenience, the following 
information in regard to the death of 



rho died at on . 



191... 



If you will consult the enclosed list of indefinite causes of death, it may help to 
make clear what further information is required. 

This information is sought only for statistical purposes and will not be made public. 

Very respectfully 

M.D. 

Asst. Registrar of Records. 



This sheet is to be returned. Use space below for answer. 



If more space is required use other side of this sheet. 

DEPARTMENT OF HEALTH OF THE CITY OF NEW YORK- 
BUREAU OF RECORDS. 

Unsatisfactory Terms used in Certifying the Cause of Death. 



Undesirable Terms. 
(It is understood that the term criti- 
cized is in the exact form given below, 
vrithout further explanation or quali- 
fication.) 



Reason Why Undesirable and Suggestion for More 
Definite Statement of Cause of Death. 



Abortion" and " Miscarriage' 



A hsrfss 



The period of gestation and. the cause of the abor- 
tion or miscarriage should be stated clearly upon 
the certificate. 

If the abortion was induced because of any dis- 
ease from which the mother may have been 
suffering, the disease should be stated upon the 
certificate of death. 

If the abortion or miscarriage was criminally 
induced, the coroners' office must be notified, if 
possible, a sufficient length of time before death, 
to permit of the coroner's securing an antemortem 
statement from the patient. 

May be tuberculous, gonorrheal, from appendicitis 
etc., or relate to any part of the body. The 
return is worthless. State cause (in which case 
the fact of "abscess" may be quite unimportant) 
and location. 



Censuses 



839 



Undesirable Terms. 
(It is understood that the term criti- 
cized is in the exact form given below, 
without further explanation or quali- 
fication.) 



Reason Why Undesirable and Suggestion for More 
Definite Statement of Cause of Death. 



Apoplexy" 



'Asthma" 

Atrophy" " Debility" "Decline" 
' ' Exhaustion ," " Inanition , ' ' 
"Weakness" 

Bronchitis" 



Cancer," "Carcinoma," 
coma," etc. ... 



"Sar- 



Cardiac Dilatation' 



' Cerebral Hemorrhage, 
cranial Hemorrhage, 
cranial Hemorrhage" 



' Intra- 
'' Infra- 



' Congestion," "Congestion of 
bowels," " Congestion of brain," 
"Congestion of kidneys," "Con- 
gestion of lungs," etc. 



1 Convulsions ' 



Croup" 



Is the terminal incident in the course of some other 
disease, e. g., arteriosclerosis, nephritis, heart 
disease, syphilis, alcohol and other poisoning, 
leukemia, etc.? 

The primary cause of death is required for statis- 
tical purposes. 

When a history of syphilis is obtained, that fact 
should be stated upon the certificate or in an 
accompanying letter. 

State whether secondary to heart or kidney lesion. 

Frequently cover tuberculosis and other definite 
causes. Name the disease causing the condi- 
tion. 

Was it acute or chronic? If it extended to pneu- 
monia the death should be reported as broncho- 
pneumonia. 

Chronic bronchitis frequently disguises pulmonary 
tuberculosis. 

Was the death caused by consumption? 

In all cases the organ or part first affected by cancer 

should be specified. 
Also state whether an operation was performed and 

whether it was radical or palliative. 

This term has become worthless because of the 
careless use of the term when terminal paralysis 
of the heart is meant. 

The term should not be used unless there was a 
true dilatation of the heart. 

Cerebral hemorrhage may be the final manifesta- 
tion of heart, kidney or other disease, or the 
result of violence. It should be made clear on 
the certificate if antecedent cause existed; if 
traumatic, the nature of the trauma should be 
stated. 

Alone, the word "congestion" is worthless, and in 
combination it is almost equally undesirable. If 
the disease amounted to inflammation, use the 
proper term (pneumonia, nephritis, enteritis, 
etc.); merely passive congestion should not be 
reported as a cause of death when the primary 
disease can be ascertained. 

Simply a symptom of disease such as scarlet fever, 
nephritis, gastro-enteritis, pneumonia, etc. 

Certificates will be returned for more definite 
statements as to the cause of the convulsions. 

"Croup" is a most pernicious term from a public 
health point of view, is not contained in any form 
in the London or Bellevue Nomenclatures, and 
should be entirely disused. Write diphtheria when 
this disease is the cause of death. 



840 



VITAL STATISTICS 



Undesirable Terms. 
lit is understood thai tlu* term oriti- 
oised is in the exact form given below, 
without further explanation or guali- 
fieation.) 



Reason Why Undesirable and Suggestion for More 

Definite Statement of Cause of Death. 



Dropsy' 



Eclampsia 



Erysipelas" 



Gastritis," "Acute indigestion' 



Heart disease," "Heart trouble, 
even "Organic heart trouble" 



Heart failure," "'Cardiac weak- 
ness" "Cardiac asthenia," "Pa- 
ralysis of the heart," etc. 



Hemorrhage," "Hemoptysis" 



"Hydrocephalus" .... 

"Hysterectomy" .... 

"Inanition," "Infantile atmphij,'' 
"Infantile marasmus" . 



Infantile paralysis" 



Malignant ," "Malignant disease" 



Marasmus'' 



"Dropsy" should never be returned as the cause 
of death without particulars as to its probable 
origin. 

Dropsy is only a symptom of diseases of the heart, 
liver, kidneys, etc., and the disease which caused 
the dropsy and death should be stated. 

This term simply means convulsions. State the 
cause of the convulsions, whether puerperal. 

State whether it was of traumatic origin or not. 

When traumatic, the exact nature of the trauma 
should be stated, as it is frequently necessary 
to refer such cases to the coroner's office for 
investigation. 

Frequently worthless as a statement of the actual 
cause of death; the terms should not be loosely 
used to cover almost any fatal affection with 
irritation of stomach. 

Some cavil at the probable correctness of such 
returns, and it is better to state clearly the exact 
form of the cardiac affection, as mitral regurgita- 
tion, aortic stenosis, or even as valvular heart dis- 
ease, rather than to use the less precise language. 

"Heart failure" is a recognized synonym, even 
among the laity, for ignorance of the cause of 
death on the part of the physician. 

Certificates will not be accepted which give any 
of these modes of dying as the cause of death. 

Frequently mask tuberculosis deaths from injuries 
(traumatic hemorrhage), puerperal hemorrhage, 
or hemorrhage after operation for various condi- 
tions. Name the disease causing death in the 
course of which the hemorrhage was an incident. 

Was it congenital or was it tuberculous meningitis? 

See Operation. 

These are pernicious terms and responsible for a 
multitude of worthless certificates. Whenever 
possible, the deaths causing them should be 
stated. Whether "syphilis," "tuberculosis," 
"cholera infantum." 

This term is sometimes used for paralysis of infants 
caused by instrumental delivery, etc. The im- 
portance of the disease in its preseDt endemic 
and epidemic prevalence in the United States 
makes the exact and unmistakable expressions 
acute anterior poliomyelitis or infantile paralysis 
(acute anterior poliomyelitis) desirable 

Should be restricted to use as qualification for 
neoplasms; see Tumor. 

This term covers a multitude of worthless returns, 
many of which could be made definite and useful 
by giving the name of the disease causing the 
"maramus" or wasting. It has been dropped 
from the English Nomenclature since 1885 ("Mar- 
asmus, term no longer used"). The Bellevue 
Hospital Nomenclature also omits this term. 



CEXSUSES 



841 



Undesirable Terms. 
(It is understood that the term criti- 
cized is in the exact form given below, 
without further explanation or quali- 
fication.) 



Reason Why Undesirable and Suggestion for More 
Definite Statement of Cause of Death. 



Meningitis," "Cerebral menin- 
gitis" "Cerebrospinal menin- 
gitis" "Spinal meningitis" 



Nephritis* 



Old Age' 



Operations," "Surgical opera- 
tion," "Surgical shock," "Am- 
putation," "Hysterectomy." 
"Laparotomy " etc 

"Paralysis," " Ge?ieral paralysis," 
"Paresis," "General paresis," 
"Palsy," etc 



Peritonitis" 



'Phlebitis" . . . 
'Puerperal Diseases" 



Only two terms should ever be used to report 
deaths from cerebrospinal fever, synonym, epi- 
demic cerebrospinal meningitis, and they should be 
written as above and in no other way. It matters 
not in the use of the latter term whether the 
disease be actually epidemic or not in the locality. 
A single sporadic case should be sc reported. The 
first term (cerebrospinal fever) is preferable because 
there is no apparent objection to its use for 
any number of cases. Xo man can intelligently 
classify such returns as are given in the margin. 
Mere terminal or symptomatic meningitis should 
not be entered at all as a cause of death ; name the 
disease in which it occurred. Tuberculous menin- 
gitis should be reported as such. 

When meningitis results from trauma, the exact 
nature of the trauma should be stated, as it is 
found necessary to refer many such cases to the 
coroner. 

"Nephritis" is frequently a complication of an 
acute infectious disease. If such is the case it 
should be made clear in the certificate. 

This is not a satisfactory return; the influence of 
age is shown by the statement of age in years, 
months and days; to this, the statement of old 
age as the cause of death adds nothing of value, 
and the disease to which the old person succumbs 
: must be stated. 

All these are entirely indefinite and unsatisfactory 
— unless the surgeon desires his work to be held 
primarily responsible for the death; always state 
the disease, or condition, which made the operation 
necessary. 

The vague use of these terms should be avoided, 
and the precise form stated, as acute ascending 
paralysis, paralysis agitans, bulbar paralysis, etc. 
Write general paralysis of the insane in full, not 
omitting any part of the name; this is essential 
for satisfactory compilation of this cause. Dis- 
tinguish paraplegia and hemiplegia; and in the 
latter, when a sequel df apoplexy or cerebral hemor- 
rhage, report the primary cause. 

The cause should always be stated. Was it tuber- 
culous or a complication of some other morbid 
condition? Was it secondary to gastric ulcer, 
intestinal ulcer (typhoid, etc.) or metritis (puer- 
peral or otherwise)? Was it traumatic, if so 
state exact nature of trauma. When peritonitis 
is puerperal that fact should be made clear in the 
certificate, specifying also whether it followed a 
full term labor or miscarriage or abortion; if either 
of the latter two, the cause thereof should be 
stated. 

What was the cause, was it puerperal? 

Whenever death results within one month after 
labor, or from a disease secondary to labor, that 
fact should always be stated in the certificate. 



Undesirable Terms. 
ilt is understood that the term oriti- 
oissd is in the exactform Riven below, 
without further explanation or quali- 
fication.) 



Reason Why Undesirable and Suggestion for More 
Definite Statement of Cause of Death. 



"Pneumonia," "Typhoid pneu- 
monia" 



''Ptomaine poisoning" "Autoin- 
toxication,'" "Toxemia" etc. 



"Rheumatism' 



"Statement of Operation' 



"Septicemia" 



Tuberculosis" 



Tumor," "Neoplasm," "New 
growth" 



Uremia" 



Pneumonia without qualification should never be 
returned as the cause of death. It should be 
clearly stated as either bronchopneumonia, lobu- 
lar pneumonia, lobar pneumonia or croupous 
pneumonia. 

The term "typhoid pneumonia" should never be 
employed. State clearly whether it was typhoid 
fever with complicating lobar or bronchopneu- 
monia. 

When pneumonia occurs as a complication of 
some other disease, the primary disease should 
be reported: As measles followed by broncho- 
pneumonia, influenza, pneumonia. 

When pneumonia follows upon an operation, the 
condition for the relief of which the operation 
was performed, should be stated. 

Hypostatic pneumonia is merely a terminal con- 
dition, and should not be reported as the cause 
of death. State the disease that caused death. 

These terms are used very loosely and it is impos- 
sible to compile statistics of value unless greater 
precision can be obtained. ' ' Ptomaine poisoning ' ' 
should be restricted to deaths resulting from the 
development of putrefactive alkaloids or other 
poisons in food, and the food should be named, as 
ptomaine poisoning (mussels), etc. Such terms 
should not be used when merely descriptive of 
conditions arising in the course of diseases, but 
the disease causing death should alone be named. 

State whether acute or chronic. 
If chronic rheumatism, note any of organic diseases 
of the heart, or other organs resulting therefrom. 

The Department desires to obtain information as 
to whether an operation was performed in all 
cases of deaths reported from the different forms 
of cancer, appendicitis and other operable diseases. 

Kindly state, therefore, whether an operation was 
performed, and, if possible, whether it was radical 
or palliative. 

The cause should be always stated and if the result 
of traumatism, the exact nature of the trauma 
specified. 

In women of child-bearing age it is necessary to 
state whether the septicemia was puerperal or 
not. If puerperal, did it follow a full -term labor 
or abortion? If a miscarriage or abortion, what 
was the cause thereof? 

The organ or part of the body affected should 
always be stated, as tuberculosis of the lungs, 
tuberculosis of the spine, tuberculous meningitis, 
acute general miliary tuberculosis, etc. 

These terms should never be used without the 
qualifying words malignant, non-malignant, or 
benign. If malignant, they belong under cancer, 
and should preferably be so reported, or under the 
more exact terms carcinoma, sarcoma, etc. In all 
cases the organ or part affected should be specified. 

Name the disease causing death. 



Acknowledgment is made to the Federal Census Bureau for much of the above subject- 
matter which has been taken from its latest manual. 



CENSUSES 843 

In conjunction with this letter a second form, a list of undesirable 
returns, is also sent. Upon the return of the query by the physician 
the original assignment of the cause of death is revised by the statistical 
office. 

Undoubtedly the diagnoses given in certificates of death today 
are more accurate than were those given in certificates of death in 
years gone by, and as time goes on the cause of death as given in 
certificates will become more and more accurate. This fact does 
not justify us in discarding all mortality statistics. On the contrary, 
they have been of the greatest value in public health work and form 
the very basis of insurance. There is one precaution, however, that 
should be observed when studying mortality statistics, especially if 
the study extends back over a number of years, and that is to examine 
the mortality of diseases in groups rather than of separate diseases, 
e. g., it would be unwise to base any conclusions on tabulation of the 
mortality statistics of apoplexy because in recent years physicians 
have, to a greater extent than heretofore, certified the primary con- 
dition usually arteriosclerosis, nephritis or heart disease, of which the 
apoplexy was but a closing incident. But if we consider the entire 
group consisting of apoplexy — diseases of the arteries, heart disease 
and nephritis — we will be able to draw very definite conclusions that 
will not be open to criticism by even the most skeptical. 

Before attempting to compare the mortality of the remote past 
with that of the immediate past we should carefully go over the ground 
in order to determine what influences have been exerted upon the 
reported mortality of certain diseases by changes in method of assign- 
ment, by more intensive querying of physicians, by improved methods 
of diagnoses, .etc., and where, because such influences have been 
operative, separate causes of death are found to be unreliable for 
comparison, we should select groups of diseases in order that we may 
without fear of criticism draw deductions from the accumulated data. 
A note of warning should be sounded as to the usefulness of studies 
made of such causes of death as syphilis, gonorrhea and alcoholism 
because of the hesitancy on the part of physicians to report such 
diseases as the real cause of death. In fact, only among the free 
hospital patients is it usual for physicians to report such diseases as 
causes of death. 

In Switzerland this difficulty has been overcome in a measure by a 
dual system of reports. Briefly, this system consists of two reports— 
the first which contains the family and personal history of the deceased 
and is used for all legal purposes, and the second report which is filed 
by the attending physician without the name of the deceased or 
other information that would identify the person to whom it refers 
and which contains all the information required for statistical purposes. 

International Classification of Diseases and Causes of Death- 
It is of primary importance that statistics be uniform. Until rather 
recently almost every country tabulating statistics had a classification 
of its own, and while such classifications answered all local purposes, 



Ml 



VITAL STATISTICS 



they prohibited the comparison of statistics of one country with those 
of another. Indeed, as late as 1893 no two countries in the world 
employed precisely the same forms and methods of statistical classi- 
fication of causes of death. The lack of such uniformity rendered 
statistical results incomparable. 

At the session of the International Statistical Institute held in 
Chicago, in L893, Dr. Jacques Bertillon presented a draft of the 
classification now known as "The International Classification of 
Causes of Death." The classification proposed by Dr. Bertillon 
was adopted by several countries, and in 1901 was adopted by the 
Bureau of the Census, the Health Department of the city of New 
York and the statistical offices of a few^ other cities. In 1911 the 
Registrar-General of England and Wales adopted the International 
Classification, so that at present many of the countries of the world 
are using the International Classification; among those not using it 
are Germany, Austra, Hungary, Switzerland and Japan. 

The International Classification is nothing more than a complete 
list of all diseases and causes of death grouped under one hundred and 
eight-nine titles. It lays no claim to being ultra-scientific, its purpose 
being to supply a practical working classification that can without 
derangement and consequent loss of comparability be brought up to 
date from time to time. The diseases and causes of death given in 
the International Classification are divided into several large groups : 

1. General diseases. 

2. Diseases of the nervous system and the organs of special senses. 

3. Diseases of the circulatory system. 

4. Diseases of the respiratory system. 

5. Diseases of the digestive system. 

6. Non- venereal diseases of the geni to-urinary system and annexia. 

7. The puerperal state. 

8. Diseases of the skin and cellular tissue. 

9. Diseases of the bones and the organs of locomotion. 

10. Malformation. 

11. Earlv infancy. 

12. Old age. 

13. External causes. 

14. Ill-defined diseases. 

In assigning causes of death under this classification the procedure 
is for the assigning officer to determine which was the primary or the 
most important cause if two or more causes are stated upon the 
certificate of death. This cause of death is given first place in the 
assignment and the other diseases or conditions are assigned in the 
order of their importance as complications. The following are several 
examples of the method of classification: If the death is reported as 
due to measles and bronchopneumonia preference is given to the 
contagious disease, measles, and pneumonia is assigned as the com- 
plication. If two contagious diseases are given as the cause of death, 
e. g. f scarlet fever and diphtheria, scarlet fever as the more fatal disease 



CENSUSES 845 

is given the preference and the death is assigned to that cause with 
diphtheria as the complication. It is a general rule that when two 
diseases are given as the cause of death, one of which is an infectious 
disease, the preference be given to the infectious disease, e. g., pul- 
monary tuberculosis and organic heart diseases, preference is given 
to pulmonary tuberculosis. If a person while suffering from some 
disease, even though it be usually fatal in its termination, meets with 
an accident or is murdered or commits suicide, preference is given to 
the accidental cause, or to homicide or suicide. It is unnecessary in 
this chapter on statistics to give further rules for assigning joint 
causes of death as they will be found in the manual of the International 
Classification issued by the Bureau of the Census, copies of which may 
be obtained upon request. The Bureau of the Census also publish a 
manual on joint causes of death. While this list of assignments of 
joint causes is helpful, particularly when the assigning is entrusted to 
lay persons, it does not in all cases give best results because frequently 
physicians in their certificates will give some clue as to the more impor- 
tant cause of death, and it is not too much to say that mortality 
statistics based upon assignments made by a competent physician 
judging each case on its own merits are of more value than those 
based upon a routine procedure. 

Mechanical Methods of Tabulating.— Where the number of certifi- 
cates of death, births, marriages handled are small the usual method 
is to make the tabulations by hand. Where, however, the volume 
of work is sufficiently large to warrant the expense of installation a 
great saving in time and labor and improvement in accuracy is obtained 
by use of electric sorters and counters. The system was originally 
devised by Hollerith, after whom the first sorters and counters were 
named. At the present time there are several firms manufacturing 
machines of this kind, the best known being the Hollerith and the 
Powers machines. 

Morbidity Statistics. — While morbidity statistics are the most 
neglected branch of vital statistics, they are, nevertheless, perhaps the 
most important. Morbidity, to a greater extent than mortality, 
determines the prosperity of a community. Mortality statistics 
shed light upon the cases of illness that terminate fatally. They 
shed no light upon the far more numerous cases of illness wherein 
the human organism is seriously and ofttimes permanently impaired, 
its efficiency lowered and its life shortened. The mortality statistics 
further shed no light upon the amount of suffering caused by sickness 
and the financial loss occasioned to individuals and families in the 
community — for the most part by preventable causes. The reason 
that morbidity statistics have been neglected is the difficulty and 
expense attending their collection; but as the death-rate gradually 
reaches that point at which it must of necessity become more or less 
stationary, the importance of securing morbidity statistics looms 
greater and greater, and for that reason there have been concerted 
efforts made to accumulate morbidity statistics that will be of value 



846 VITAL STATISTICS 

in public health and social work. Likewise, the advent of such social 
and economic Legislation as employers' liability insurance and compul- 
sory illness insurance makes the collection and tabulation of illness 
statistics almost mandatory. Without such statistics it is impossible 
to compute equitable illness insurance rates. 

The only morbidity statistics available at the present time are the 
reports of preventable diseases, and practically no use is made of 
these statistics except for administrative purposes. This group of 
morbidity statistics owes its origin to the efforts of health depart- 
ments to control the acute contagious diseases. It was evident to 
those interested in the control of these diseases that knowledge of 
the presence of such diseases must be acquired in order to take the 
necessary measures to control them and to prevent their spread 
through isolation, vaccination and immunization. With the advent 
of active campaigns against pulmonary tuberculosis this disease was 
added to the list of reportable diseases. As our knowledge of etiology 
expanded through bacteriological studies still other diseases were 
added to the list. 

The degree of completeness attained by various communities in 
the reporting of contagious and communicable diseases varies and if 
the degree of completeness of the registration of births may be accepted 
as an index of the efficiency of a. registrar, so too the completeness of 
the registration of communicable diseases may be accepted as an 
index of the efficiency of a health officer. It is evident a health 
officer cannot efficiently control the incidence of these diseases in the 
community under his jurisdiction unless he receives prompt and 
accurate information of every case occurring within his district. 
The reporting of preventable diseases is usually provided for in the 
State health laws, city charters and the sanitary codes of cities and 
States which are based upon the said laws or charters. In few cities 
of the country have vigorous campaigns to secure complete registra- 
tion of preventable diseases been carried on. There seems to be a 
reluctance on the part of the health officers to punish physicians for 
their derelictions in reporting these diseases. As Newsholme points 
out in his volume on vital statistics the reporting of preventable 
diseases should be made compulsory in order to relieve physicians of 
the criticism by their patients for reporting these diseases and to 
absolve them of charges of betraying professional secrecy. The 
reporting of these diseases having been made compulsory, the law 
should be strictly, impartially and vigorously enforced. The good 
will and cooperation of physicians in reporting contagious diseases 
should be given by them to health departments in return for the free 
laboratory service rendered them in diagnosing diseases susceptible 
of diagnosis by laboratory methods. Aside from the advantages 
accruing to the Department of Health by closer and more friendly 
cooperation from physicians secured in this way, it places at the 
disposal of physicians, scientific means of verifying diagnoses and 
of doing so at an earlier period than would be possible without such 
laboratory assistance. 



CENSUSES 847 

In most States the plan of reporting notifiable diseases is to have 
the physicians notify the health officer of the locality in which the 
case occurs. This officer, in turn, is required to transmit a copy of 
the report to the State Department of Health. In many of the large 
cities such as New York where the Health Department is not under the 
jurisdiction of the State Department of Health there is no provision 
for the transmission of reports to the State Department, except in 
the form of a summary at the end of each month. In many 
other than cities of the first class the wisest plan is to follow the same 
procedure in enforcing registration of preventable diseases, as was 
outlined in the chapter on the enforcement on the registration of births. 

Since it is essential that there be uniformity in all statistics in order 
that they may be comparable it is desirable that a model law similar 
to the model law for the registration of deaths and births be provided 
and submitted to the various States for enactment. 

Uses of Reports. — While the reports of preventable diseases have 
been of greatest value in controlling the diseases reported, but little 
time or energy has been devoted to the careful and scientific study 
and analysis. The city of Boston some time ago adopted a system 
of tabulating the reports of the preventable diseases by means of 
electric sorting devices. The city of New York is about to adopt a 
similar system whereby it will be possible to approach the matter from 
a broader point of view and to analyze the etiology of these diseases 
in a more intensive manner. Information that would be of inestima- 
ble value in the control of venereal diseases could be obtained from 
the reports of these diseases were they available. 

Occupational Statistics. — The attention of the health officers and of 
those interested in public health work has within recent years been 
focussed upon the diseases caused by occupation and upon industrial 
accidents. The outcome of this interest has been the enactment of 
laws requiring that occupational diseases and accidents be reported 
either to the State Health Department or the State Factory Depart- 
ment. These reports furnish a fund of valuable information if they 
are but properly segregated, tabulated and analyzed. Probably no 
other country in the world is so wasteful of its man power and of 
human life as is the United States. 

With the advent of pure food legislation it became compulsory in 
many communities within the United States for persons engaged in 
the handling of food products, particularly, bakers, cooks, etc., to be 
examined twice a year to determine their freedom from communicable 
diseases. The results of these examinations supply another source 
of morbidity statistics of which little use has been made up to the 
present time. The establishment of occupational clinics wherein 
persons suffering from diseases to which they had been exposed by 
reason of their occupation, has furnished us with another source of 
very valuable statistical information. Isolated studies of these 
statistics have been made by progressive health officers but there is 
as yet no universal scheme of handling these valuable data. 



848 VITAL STATISTICS 

The examination of school children by physicians and nurses in 
the employ of the Department of Health or the Department of Edu- 
cation, as the case may be, has resulted in the accumulation of a vast 
store of very valuable information, of which, up to the present time, 
but little practical use has been made except in solving the immediate 
administrative problems presented. The employment of physicians 
and nurses by large industries to safeguard the health of the employees 
of these industries has been a great step forward in the control of 
illness, but up to the present time no universal system for the collec- 
tion, tabulation and analyses of these statistics have been adopted. 
Such a system was devised and urged in this city several years ago by 
the authors but up to the present time no headway has been made. 

One of the most recent methods of measuring community illness is 
the illness census. As the name implies it is a census of persons ill on 
a given day. Three such censuses have been taken w T ithin the last 
year and a half by the New York City Department of Health, and 
several have been taken in the different parts of the country by the 
Metropolitan Life Insurance Company. These censuses furnish very 
important and valuable information as to the amount of illness preva- 
lent at the time of the census, but they have the shortcoming that they 
are but snapshots of conditions at a particular time. To make use 
of a rather crude simile, a census of this kind is but a "snapshot" and 
not a "movie." 

Statistical Errors to be Avoided. — Quetelet laid down four principal 
rules for avoiding statistical fallacies and if the health officers will 
hold them in mind they will not fall into grievous statistical errors: 

1. Never have preconceived ideas as to what the figures are to prove. 

2. Never reject a number that seems contrary to what you might 
expect merely because it departs a good deal from the apparent 
average. 

3. Be careful to weigh and record for all the possible causes of an 
event, but do not attribute to one what is really the result of a com- 
bination of several. 

4. Never compare data which have nothing in common. 

In the previous chapters we have called attention to several of the 
more common statistical errors but for the purpose of reference it 
may be well to group the more common causes of error in one chapter. 

Population. — Since population is the basis upon which the presenta- 
tion of all vital statistics depends we shall consider it first. Inaccurate 
estimates of the population are a frequent source of error. The 
further removed the period for which the population is estimated is 
from the date of the census the greater is the liability of error. This 
is particularly true in a newly settled community, where the increase 
in population depends more upon immigration than upon the excess 
of births over deaths. In a case where the estimate of the population 
is doubtful precaution should be taken to check the estimate by 
various methods. The following means suggests themselves: Com- 
parison of estimate with the registration rolls of the Board of Election; 



CENSUSES 849 

the number of inhabited houses multipled by the average number 
of persons per house as obtained at the previous census; school regis- 
tration will furnish another check inasmuch as it gives the number 
of children at school ages and if we assume that children make up 
the same percentage of the total population as at the last census we 
can readily estimate the total population from the school population. 
Still another method of value is to ascertain the birth-rate at the 
last census and upon the assumption that the birth-rate remains 
fairly constant estimate the population in any post-censal year by 
multiplying the births reported for the year by 1000 and dividing by 
the birth-rate of the last census year. 

Registration for selective service in the army and navy may be 
used as a basis for estimating the total population of a city, State or 
nation. 

In comparing rates, whether death-rates, birth-rates, marriage-rates 
or sickness-rates, care must be taken to make allowances for difference 
in the sex and age constitution of the population groups whose rates 
are compared. We have shown in the previous chapters how the 
difference in the age and sex constitution of a population effects its 
mortality, its illness and its birth-rates. When comparing the mor- 
tality-rates of different occupational groups this source of error must 
be guarded against because the average age of persons engaged in 
different occupations varies within wide boundaries and as death- 
rates vary from year to year of life it is at once apparent that this 
difference in age constitution will, aside from all other influences, 
cause a marked diversion in the rates for the occupational groups 
under observation. There are two methods of correcting errors due 
to differences in age constitution: (1) By means of corrected or 
standardized death-rates; (2) by the use of life tables. 

Errors from Paucity of Data. — One should guard against making 
sweeping deductions upon insufficient data. When cases or observa- 
tions are inconsiderable in number or the time of exposure short, 
deductions are of questionable value except in certain instances; for 
example, it is perfectly proper to compare the death-rate of the same 
community for one week with the previous week or to study weekly 
rates of the same community week after week; but it is statistically 
improper to compare the weekly mortality of two different communi- 
ties for so short a period as one week, especially if one is a large, the 
other a small, community. 

Percentages. — The use of percentages in the presentation of statis- 
tical facts should be avoided except in certain instances where it is not 
possible because of the absence of necessary data to compute rates. 
The reason that percentages are an unsatisfactory medium for the 
presentation of statistical facts is that if a certain group of facts or 
observations are stated as a percentage of a whole the percentage of 
this group under observation will depend upon the size of the other 
groups as well as upon its own size. For example, if in a group of 1000 
infants there were 25 deaths from diarrheal diseases and 75 deaths 
54 



850 VITAL STATISTICS 

from all other causes the percentage of deaths from diarrheal diseases 
would be 25 per cent.; if in the same group of 1000 infants there were 
25 deaths from diarrheal diseases and 125 deaths from all other causes 
then diarrhea caused but 10 per cent, of the total number of deaths, 
notwithstanding the fact that the number of deaths from diarrheal 
disease remained the same and the death-rates based upon the number 
of deaths from this cause and the total number of infants under 
observation would be the same in both instances. 

Errors from Compounding Death-rates. — The death-rates of a com- 
munity cannot be obtained by finding the numerical average of the 
death-rates of the different boroughs or wards of that community. 
For example: If the death-rate of the Borough of Manhattan was 
9.11, the borough of the Bronx 8.97, the borough of Brooldyn 9.31, 
the borough of Queens 12.21, and the borough of Richmond 13.34, 
the death-rate of the city would not be 10.59 but 9.45 because the 
populations in which the deaths occurred are not the same in all 
boroughs. Therefore, the death-rate of the borough of Manhattan 
would exert a greater w T eight in the death-rate of the city than would 
the death-rate of the borough of Richmond where the population is 
small. Of course, it is possible by weighting the different rates to 
obtain a weighted average closely approximating the true death-rate 
of the city, but it is far easier to compute the death-rate for the entire 
city upon the total number of deaths and the total population. 

Errors Due to Difference in Classification. — In making comparisons 
between mortality of any disease in the same community for a period 
of years or in making comparisons of mortality of diseases in different 
communities for the same period great care must be exercised to make 
corrections for differences in methods of classification. Even when 
comparing statistics classified according to the international classifi- 
cation we must include in our comparison all diseases of each group. 
Perhaps we may make our point clearer by concrete examples. Some 
time ago while making a study of pulmonary tuberculosis in foreign 
and native cities we encountered a foreign city with an exceptionally 
low tuberculosis rate, so low in fact that it aroused suspicion as to its 
correctness. Upon examination of the complete mortality returns of 
this city we found that its death-rates from bronchitis, bronchial 
asthma and pulmonary hemorrhage were excessively high and that 
if we included the deaths from these causes as given in its report and 
also included the deaths from these causes as stated in the reports of 
the other cities under comparison we found that the combined mor- 
tality of tuberculosis and other diseases of the respiratory system 
was higher in the community that boasted of the low tuberculosis 
rate than in most of the other communities under consideration. 
Another example : If comparison is made of the mortality of apoplexy 
during recent years with past years it will be found that mortality 
from this cause has declined tremendously, but if we examine the 
statistics more closely we will find that this decrease has been in 
large measure caused by more careful assignments and consequent 



ESTIMATING POST- AND INTERCENSAL POPULATIONS 851 

transfer of deaths to other assignments. In other words, since apo- 
plexy is the closing incident of arterial sclerosis, Bright's disease and 
chronic endocarditis, our comparison should be based upon the mor- 
tality of all these diseases and not upon the mortality of anyone of 
them. Another example is to be found in the statistics of typhoid 
fever. In early years many cases of typhoid fever were diagnosed 
as typho-malaria, etc., therefore, deaths from these causes as well as 
from typhoid fever should be included in any statistics upon which 
comparisons are to be made. Similarly in making up statistics for 
a series of years from cancer care should be taken to include all titles 
under which deaths from cancer might be classified. The titles 
under which many deaths from cancer are to be found is that of 
"tumors." 

In comparing the mortality of diseases of infancy we must be 
careful to include in our statistics all the titles under which deaths 
might be classified. In the past many deaths which are now classified 
as gastro-enteritis were formerly classified under dysentery, cholera 
nostras and similar titles, and deaths that are now classified under 
the heading of prematurity, malnutrition, etc., were formerly classified 
under the title of "ill-defined causes." Another common source of 
error is to be found in the statistics of deaths from accidental poison- 
ing by illuminating gas and accidental drowning. The error in these 
two causes is that in many deaths from both causes the coroner or 
medical examiner is unable to determine from the evidence at hand 
whether the death was accidental, suicidal or homicidal and conse- 
quently he reports the death as due to illuminating gas poisoning or 
drowning, as the case may be, without qualifications and since there 
is no provision made for a separate classification title for these deaths, 
they are perforce included in the deaths from accidents, therefore in 
comparing the statistics of suicides by illuminating gas one should 
bear in mind that the diligence of the medical examiner in ferreting out 
evidence is an important determining factor in the mortality from 
this cause. The same is true in the statistics of drowning, both acci- 
dental and suicidal. 



GEOMETRICAL METHOD OF ESTIMATING POST- AND INTER- 
CENSAL POPULATIONS. 

The arithmetical method has been explained in the previous chapter 
and in it the assumption is made that the annual increase or decrease 
in population as ascertained by comparison of the figures of the popu- 
lations obtained in the last two enumerations or censuses maintains 
during the years between the censuses and those succeeding the last 
census year. The annual increase or decrease is the same during each 
year and may be compared to a sum in simple interest. 

The geometrical method, on the other hand, assumes that the 
same rate of increase maintains as occurred in the previous intercensal 
period and that the amount of annual increase is in proportion to the 



852 VITAL STATISTICS 

population, thus taking- cognizance of the annual increase of persons 
of marriageable ages and consequently the annual increase in the 
number of parents and of living born children. The geometrical 
method is the one employed by European statisticians and has given 
more approximately correct estimates in the experience of the city of 
New York, in which the natural increase in the population remains 
fairly constant. It is evident that according to this method the 
calculations are similar to those in computing compound interest. 

Let /• equal the annual rate of increase per unit of the population; 
then each unit at the end of the first year will equal 1 + r; at the 
end of the second year (1 + r) 2 and so forth. Let P represent the 
population at the beginning of the first year, which at the end of the 
first year will equal P (1 -f- r), at the end of the second year, P (1 + r) 2 
and so forth. The value of r can be ascertained from the populations 
at the two last censuses. 

If P = the population in 1900 and P\ = the population in 1910, 
then P 1 = P (1 + 4) 10 . 

Taking the logarithm of each side of the equation we have : log P 1 
= logPH- 10 log (1 + r). 

Transposing: log P 1 — log P = 10 log (1 + r), log (1 + r) = T V 
(logP 1 - logP). 

From a book of logarithms the value of 1 + r is readily obtained. 
It must be remembered that the population at the middle of the 
year is always taken as the basis of calculation of mortality-rates, 
thus making it necessary to make estimates of the mid-year population 
even in a census year. 

Specific and Standardized Death-rates. — A perusal of what has 
been said in relation to death-rates furnishes a basis for a more detailed 
procedure to be adopted in making comparisons of the crude death-rates 
of various cities or countries. It can be readily grasped that specific 
death-rates, that is, rates from certain specified causes or at specified 
ages may be quite readily compared with those of other communities. 
The infant mortality-rate based upon 1000 births in a city may be 
compared with that of any other city without the necessity of applying 
corrective methods; so may the death-rate of children under five 
years of age be compared with a similar rate in various communities 
and so may the death-rates at any age or any age group as occurring 
in one community, city, State or country be compared with those of 
other communities. 

The death-rate per 1000 of the entire population from certain 
causes of death occurring at and limited to certain age groups may 
be safely compared with similar rates in civilized communities, as for 
instance the death-rates from measles, scarlet fever, diphtheria, whoop- 
ing-cough and diarrhea. On the other hand, the comparison of crude 
death-rates as experienced in one community with those of another are 
likely to lead to erroneous conclusions. Hence, if the age constitu- 
tion of the population of one city, State or country is radically dis- 
similar to that of any other city, State or country the crude death-rate 






ESTIMATING POST- AND INTERCENSAL POPULATIONS 853 



of the one cannot with justice be compared with that of the other. 
An example will best show the truth of this statement: Suppose 
the cities A and B have exactly the same death-rate at the four speci- 
fied age groups in the table and exactly the same total number of 
residents but with dissimilar age groupings of the populations. 



Population. 


A. 


Death-rate 
per 1000. 


Xo. of 
deaths. 


B. 


Death-rate 
per 1000. 


Xo. of 

deaths. 


Under 1 year 

1 to 19 years . 
20 to 49 " . 
50 and over 


1,500 
20,000 
15,000 
13,500 


100 
20 
15 
60 


150 
400 
225 
310 


1,000 
20,000 
20,000 

9,000 


100 
?0 
15 
60 


100 
400 
300 
540 


Total . . 


50,000 




1,585 


50,000 


1,340 



Crude death-rate A = 31.70. 



26.80. 



It is thus seen that the difference of 4.9 points in the rates is the 
result of the dissimilar age grouping of the two populations, and of 
that alone, and that the crude death-rate does not furnish a just 
measure of comparison among communities unless the age distribu- 
tion is substantially the same, or unless means are taken to allow for 
the varying age constitution of the populations. On the other hand 
there is no good reason why the crude death-rate may not be used 
in comparison of the mortality of a community with that experienced 
by the same community during a series of years unless the age distri- 
bution has materially changed; nor is it to be discarded as a standard 
of comparison for two or more communities the age groupings of whose 
population are substantially similar. 

To eliminate the effect on the crude death-rate of the differences in 
the age distribution of populations a standard population must be 
adopted. The International Statistical Institute, in 1895, adopted 
an "Index of Mortality," based on the recommendations made by Dr. 
J. Korosi. This procedure consists in the application of the death- 
rates of five age groups in any community or country to the population 
of Sweden as ascertained at the census of 1890, the age grouping as 
shown in this census being known as the "Standard Population." 

The following is an example of the method used: 

DEATH-RATE OF NEW YORK CITY, YEAH 1911. STANDARDIZED BY 

APPLICATION OF DEATH-RATES AT AGE GROUPS TO 

STANDARD POPULATION OF SWEDEN. 



Standard population of Sweden. 



Age groups. 



Percentage by 
age groups. 



Death-rate by age 

groups, 

New York City, 

Year, 1911. 



Standardized 

death-rate, 

Xew York City. 



Under 1 year = 26,500 

1 to 20 years = 398,100 

20 to 50 " = 386,200 

50 years and over = 189,200 



0.0265 
0.3981 
0.3862 
0.1892 



Total 



= 1,000,000 



95 
11 


40 



2.617 
4.379 
2.317 
7.568 

L6.881 



854 VITAL STATISTICS 

As the death-rate under one year of age was 95 per 1000 living at 
that age and the percentage of the population under one year was 
2.65 the number of deaths per 1000 at that age group will be 95 X 
0.0265 = 2.017; the rates at the other age groups are worked out 
in similar manner and the sum of the rates will be 16.88 per 1000 of 
the entire population. As the calculated rate for the year 1911 was 
1 5 . 30 then the standardized rate was 1 . 58 points higher than the crude 
rate, thus showing that the age distribution of the city of New York 
was favorable to that extent as compared with that of the standard 
population. The correction or standardization of the crude rate of 
New York City by this method applies only to age distribution of 
the population. 

The standard population of any other country may be used rather 
than that of Sweden if so desired. 

The population of England and Wales as taken in 1901 has been 
used as a standard population by the Registrar-General for many 
years, eleven age groups by sex being employed beginning with the 
group under five years of age and ending with the group seventy-five 
years of age and over, thus making correction not only for age but 
also for sex constitution of the population. A detailed application of 
the method employed in the Registrar-General's office is to be found 
in Xewsholme's Vital Statistics published in 1899 to be had at the 
Macmillan Company, New York. 

Graphic Presentations. — A graph is a visual presentation of quanti- 
tative data in such form that he who runs may read. 

Graphs possess the following advantages over tabulated figures: 
(1) They save the time of the reader; (2) they usually take up less 
space than the tabular statements; (3) they aid materially in allowing 
the reader to form his own deductions rather than have them formed 
for him by the person analyzing the figures ; (4) they leave impressions 
on the mind more lasting than the figures themselves. 

The graphic forms most used are bars, circles, curves, maps, charts, 
quadlilstivals and cubes. The simplest form of a graph is the hori- 
zontal bar and gives excellent results in showing the component 
parts of a total. The groups may be distinguished one from the 
other by divisional lines, by various shadings or by color, the latter 
being the most expensive. The circle with its sectors is also much 
used in showing component parts, but does not appeal as quickly to 
the eye as the horizontal bar, the component parts are more difficult 
of comparison and the direction of the lettering, especially if the 
sectors arc of small dimension, are not horizontal. Vertical bars are 
often used with good effect in showing death or rates through a series 
of years. Curves may be drawn by lines connecting the tops of 
the vertical bars or may be constructed without actually drawing the 
bars. Curves are used frequently in vital statistics and are preferable 
in many instances to the vertical bar arrangement. 

Pin maps are frequently made use of to show location of illness and 
mortality by selected areas. Small glass beaded pins of varying colors 
stnek their full length into boards made of soft wood or straw serve best. 



RULES TO BE OBSERVED IN PREPARING CHARTS 855 

RULES TO BE OBSERVED IN PREPARING CHARTS. 

1. Title of chart should state clearly the subject matter and the 
duration of time, location or other modifying factors; wall charts 
should be so lettered and numbered as to be legible at usual visual 

distances. 



Under 5 to 
5 yrs. 15 yrs 



45 to 65 or 
65 yrs. over 




Fig. 118. — Deaths from Influenza and Pneumonia by age groups and percentage of total 
deaths from these two causes. Autumn 1918, City of New York. 

2. Figures for the horizontal scale should be placed at the bottom 
of the chart, but if large variations in height occur the figures may be 
placed on the top as well as the bottom of the chart and should read 
from left to right. 




Fig. 119. — Deaths in registration area in United States, 1911. Percentage of deaths 
from specified causes: Organic disease of heart, 10; tuberculosis of lungs, 9.7; Blight's 
disease, 6.9; cancer, 5.2; congenital debility, 5.6; violent deaths, 6.4; contagious 
diseases, 6.9; cerebral hemorrhage, 5.4; pneumonia, 6.3; other diseases, 37.6. 



3. The general arrangement should be from left to right. 

4. Figures for the vertical scale should be placed both on left and 
right sides of the chart and should read from bottom to top. 

5. Numerical data should be given on the chart if possible and if 
not should be printed in close proximity thereto. 




Fig. 120.— City of New York. Deaths from certain causes, year 1917. Total deaths 

from all causes, 78,575. 




Fio. 



121.— City of New York. Deaths of children under one year of age from municipal 
causes, year 1917. Total deaths of all causes under one year, 12,568. 



RULES TO BE OBSERVED IN PREPARING CHARTS 857 

6. Tunes should be made of broader lines than the coordinate lines. 

7. The zero line should be shown whenever possible and should be 
a line heavier than the coordinate; if dimensions of the chart are such 



85 
80 
























































■ 






























70 
65 
60 

< 
g50 

I 

»"45 

sx 

Ol 
LU 

535 
30 

25 

20 

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■ 
























li 










































_ 






















■l 


1 
















• 

n 


1 












mm 



















50 8 
45!: 



LU 



40 



35 



20 



15 



10 



Under 5-9 10-14 15-19 
5 yrs. 



-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-65 
AGE GROUPS 



Fig. 122. 



-Death-rates by age groups, years 1909, 1910 and 191 
States, United States. 



Original registration 



io o t- 





l^s ^ 


^ N 2 


K^V Kl .-y 


v 


t_ 


~V 


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— 


! 



Fig. 123. — Crude death-rate per 1000 of population of the City of New York, 
1898-1917 inclusive. 



858 



VITAL STATISTICS 



that it cannot be shown then a broken or wavy line should be used 
to show the incompleteness of the field. 

8. The variable line or curve should be shown as proceeding in a 

horizontal direction. 

9. In comparing curves the scales of each must be identical. 
Fig. 118 is a good example of the use of the horizontal bar. 

Fig. 119 is shown as an extremely bad example of the use of the 
circle as the data have not been placed within its boundary and as the 
eye can only grasp the various causes of death shown by movement 
of the chart. 

Pigs. 120 and 121 are good examples of circular graphs, especially 
Fig. 121 by reason of its clearness of reading. 

Fig. 122 is a good example of the vertical bar arrangement in showing 
death-rates at various age groups. 

Fig. 123 is a good example of a curve, showing the crude death-rate 
for a period of twenty years. 



ADDENDA TO CHAPTER lit. 
The following sections were inadvertently omitted from Chapter III : 

TRENCH FEVER. 

A disease characterized by febrile relapses became very prevalent 
in the different European armies during 1915 and continued until the 
end of the war; it caused a great amount of disability. Its etiology 
was studied by British and American Commissions. It is believed that 
outbreaks of a similar character appeared previously in armies and 
among crowded populations, but there is no conclusive proof. The 
symptoms are not sufficiently characteristic to identify individual cases. 

Trench fever is due to a resistant filterable virus which is present 
most abundantly in the plasma of the blood and to a less extent in the 
urine, sputum and possibly feces. It is transmitted naturally by the 
infected body louse, Pediculus humanus. The louse is itself infected 
by having previously fed upon an infected person. The eggs of the 
infected louse are apparently uninfected. The feces of the infected 
louse carry the contagion and when rubbed into a wound may transmit 
the disease. The same is true of the sputum and urine of infected 
persons. 

Prevention. — All infected persons should be disinfected as soon as 
possible by careful bathing and sponging with alcohol. The personal 
clothing and bed clothing should be disinfected by exposure to moist 
heat at 70° C, for one-half hour. Trench fever patients should be 
protected from louse infestation. In general, all practical means should 
be used to lessen louse infestation of the people. 

ENCEPHALITIS LETHARGICA. 

Within the past two years this disease has attracted much attention; 
it probably has existed for a long time. 

The work of Loewi and Strauss indicates that the disease is due to a 
filterable virus which is found in the central nervous system and also 
in the secretions of the nasopharynx. It is possible to transmit an 
infection to monkeys and rabbits when this material is injected intra- 
cerebrally. Levaditi independently, but at a later period confirmed 
this. Loewi and Strauss believe that a virus similar in form to that 
isolated from poliomyelitis is the cause of the disease. Levaditi and 
Amoss have failed to obtain cultures and Amoss was unable to infect 
animals. It is hoped that further investigations will clear up these 
differences. 

Prevention— While few if any cases have a clear history of infection, 
the disease is in all probability spread in the same way as poliomyelitis. 
Many persons probably become carriers, and of these only an occasional 
one contracts the disease. All discharges and especially those from 
the mouth and nose should be disinfected. 



INDEX. 



A 



Abandoned children, care of, 695-697 
Abscess, brain, as a result of focal infec- 
tion, 497 
of tooth root, 497 
Acetic acid, determination of, in vinegar, 

334 
Acetylene gas for illumination, 451 
Acidosis, result of unbalanced diet, 320 
Acne as a result of unbalanced diet, 320 
Actinomycosis, incidence of, 167 
incubation period of, 168 
infectious agent of, 168 
methods of control of, 168 
mode of transmission of, 168 
period of communicability of, 168 
source of infection of, 168 
Activated sludge, 434-435 
Activity, relation to personal hygiene, 473 
Ades, Calopus, 592 
Adult, mental hygiene in, 772-774 
Adulteration of food, 341-346 
of milk, detection of, 364 
Advertising as a measure in public health 

education, 740, 745 
Aerobic decomposition of organic matter, 

428 
Age, effect on mortality rate, 827 
limits of recruit, 520 
of parents, effect on infant mortality 
831 
Agglutinating and bactericidal power, 

relation between, 47 
Agglutination, macroscopic, 33 
Dreyer method, 40-41 
slide method, 41-42 
tube method, 39-40 
microscopic, 33, 38-39, 40 
reaction, diagnosis of disease, 37 
identification of organism, 36-37 
mechanism of, 32-33 
practical application of, 36-38 
pseudo-reactions, 39 
test in typhoid fever, 135 
Agglutinins, 32-42 

absorption of, 34-36 
affected by heat, 35 
and animal species, 34 
development of, 36 
group, 33-34 
major, 33-34 
normal, 33-34 
specific, 33-34 



Agglutinogen, 32 
Aggressins, 71-72 
Air. See also Atmosphere. 

amount necessary in rooms, 449 

artificial cooling, 277-278 
humidification, 269-272 

bad and good, 239-240 

composition of, 583 

distribution of, 272-274 

enumeration of bacteria in, 291-292 

examination of, 279-292 

flow measurement of, 280-282 

health and, 277-278 

in mines, 243 

movement, effects of, 248, 288-290 

pollution of, 583 

purification of, 584 

relation to personal hygiene, 473, 
499-501 

supply, standards of, 261-263 

vehicle of infection, 218 

vitiation of, 262-263 

washing, 269 

what constitutes good, 260-261 

work, by New York City Depart- 
ment of Health, 254-255, 283 
Alcohol, effect of, on masses, 488-489 

laboratory evidence of its effects, 
489-490 

mental disorders due to, 759, 761 

quantitative determination of, 334 

relation of, to degeneracy, 761 

therapeutic use of, 490 

use of, in food preservation, 331, 334 

venereal diseases and, 152 
Alcoholic beverages, adulteration of, 346 

psychoses, admissions to hospitals, 
761 
Alcoholism among soldiers, 551 

cause of death, 843 

of infant mortality, 678 

in industry, 657 

relation to feeble-mindedness, 788 
Alexin, 44 
Allergy, 65 

to foods, pollens, drugs, 68-69 
Amboceptor, 45 

Amboceptor-complement action, 45-46 
Ambulance companies, 547 
Amenorrhea, war, relation of, to diet, 735 
American National Red Cross Associa- 
tion, service of, 550 
Anaerobic decomposition of organic 
matter, 428 



862 



1XDEX 



AnaphylactOgen, 61 

Anaphylaxis, 59-61 

contraction of smooth muscle in, 

60 
in dogs, 60 
in guinea-pigs, 59 
non-specific phenomena similar to, 

6] 
passive, 60-61 
in rabbits, 59 

sensitization by enteral introduc- 
tion, 60 
symptoms of infection and, 64 
theories of, 62-64 
Ancestry, neuropathic. See Neuropathic 

ancestry. 
Ankylostomiasis. See Hookworm dis- 
ease. 
Anemia, as result of focal infection, 497 

of unbalanced diet, 320 
Anemometer, 280-282 
Anilin in production of explosives, 626 
poisoning, 609 

treatment of, 610 
uses of, 609 
Animals, species subject to infection, 23 
Anopheles, 592 
Anthracosis, 259 
Anthrax, incidence of, 169-170 
incubation period of, 170 
infectious agent of, 170 
in meat, 321 

methods of control of, 170-171 
mode of transmission of, 170 
period of communicability of, 170 
precipitin reaction in, 43 
source of infection of, 1 70 
Anti-anaphylaxis, 61-62 
Antibacterial serum for therapeutic pur- 
poses, use of, 56-58 
titration of, bleeding, 57 
concentration, 57 
cross-protection and strain 

identity, 57-58 
serum, 57 
standards, 56 
Antiblastic immunity, 72 
Antibodies, action of, 27-28 
bacteriolytic, 44-49 
cellular activity of, 31 
identification of, by complement- 
fixation reaction, 48-49 
production of, 27-28 
Anti-enzymes, 71-72 

of the host, 71 
Antiferments, 71 
Antigen, precipitin, nature of, 43 
Antimicrobal substances, 32-72 
Antimony poisoning, symptoms of, 610 

uses of, 610 
Antiprotein substances, 32-72 
Antiscorbutics, 326-327 
Antiseptics, 177 
Antitoxin, 29-31 

tetanus, use of, 154 

use of, in diphtheria carriers, 103 



Appetite, effect of odors upon, 246 
Argon in the air, 240 
Arsenic fumes poisoning, symptoms and 
treatment of, 611 
poisoning, symptoms of, 611 
uses of, in industry, 610 
Arterial changes as result of focal infec- 
tion, 497 
Artesian wells, 405 

Atmosphere. See also Relative humid- 
ity, temperature, air. 
bacterial pollution of, 257-259 
composition of, 240-242 
effect of human occupancy on, 242 
relation of, to health and efficiency, 
239-261 
Auditoria, ventilation of, 266 
Authority, sources of, for rural health 

administration, 557 
Auto-infection, microbal, 25 
Auto-intoxication as factor influencing 

physical deterioration, 473 
Autovaccination, 122 
Avisol, 240 



B 



Baby health stations, 683-690 

aims and objects of, 687 
effect of, on infant mor- 
tality, 690 
equipment of, 685-686 
organization of, 685 
types of, 684 
welfare organizations, .cooperation 
of, 694 
Bacillus coli communis. See Colon 
bacillus, 
enteritidis, 390-391 
typhosus, 131 
Welchii in water, 417 
Bacteria, adaptation of, to certain tis- 
sues, 18 
in air, 242, 257-259 

enumeration of, 291-292 
in milk, growth of, 349 

identification of, 383-384 
pathogenic properties of, 351- 
352 
relation of, to milk-borne disease, 

349-363 
in soil, 398, 400, 401-402 
in water, significance of number of, 
415-416 
varieties found, 417 
Bacterial and other contaminations of 

milk, 347-384 
Bactericidal action, determination of, 
46-47 
and agglutinating power, relation of, 

47 
power of raw milk, 380 
Bacteriological examination of milk, 365- 
368, 383-384 
standards for swimming pools, 467 
Bacteriolysin, 44 



IXDEX 



863 



Bacteriolytic action, determination of, 46 

antibodies, 44-49 
Bacteriotropins, 50 
Badge, neutrality, 550-551 
Baggage, disinfection of, 801-802 
Balance system of ventilation, 635 
Baldness, prevention of, 505 
Barlow's disease, 326 
Barracks, construction and sanitation of, 

531 
Baths, air, 502-503 
cold, 503 
hot, 504 

Jewish ritual, 467-468 
outdoor, 504-505 
Russian, 504 
sea, 504 

shower, in connection with swim- 
ming pools, 461 
tepid, 503 
Turkish, 504 
warm, 503-504 
Bathtubs, 454 
Battlefield, hygiene of, 544 
Bedbug as a germ carrier, 591-592 
Beef, measly, 396 

Bends. See Compressed air illness. 
Benzene poisoning, symptoms and treat- 
ment of, 612 
uses of, in industry, 612 
Benzidine test for peroxide in food 
Benzine poisoning, 611 

treatment of, 612 
uses of, 611 
Benzoic acid as food preservative, 
334-335 
separation and identification of, 
335-336 
Benzol. See Benzine. 
Beri beri among soldiers, 551 
in animals, 325 
diet in relation to, 735 
in man, 325 

result of unbalanced diet, 320 
rice diet in relation to, 394 
vitamines in relation to, 324 
Bichloride of mercury in disinfection of 
house and sick-room, 187 
of vessels, 804 
Binet's formula, 783 
Birth rate, effect of, on infant mortality, 
730, 831 
on mortality rate, 829 
factors influencing, 817 
methods of stating, 816-817 
relation of, to marriage rate, 
812-813 
registration, 814-850 
checking of, 227 
law, detecting violations of, 816 
statistics, 813-818 
value of, 813-814 
Births, complaints for failure to report, 
815-816 
reports of, bv attending phvsicians, 
570 



339 



330, 



! Black death. See Plague. 
Hole of Calcutta, 239 
, Blood, bacteriological examination of, in 
typhoid fever, 135 
pressure, effect of atmospheric tem- 
perature upon, 249 
Board of Health, orders of, 566 

rural, 564-567 
Body, disinfection of, 188 

temperature, effect of air tempera- 
ture upon, 249 
regulation of, 247-248 
Boiler plate, use of, 741 
Books, disinfection of, 192 
Borax, detection of, in milk, 364-365 

use of, in che clung fly nuisance, 439 
Bordet-Gengou phenomenon, 47-49 
Boric acid, detection of, in food, 337 
in milk, 364-365 
physiological effects of, 337 
use of, as a food preservative, 
337 
Bothriocephalus latus, 396 
Botulism, 392 

Bovine tuberculosis in man, 91-92 
Brain abscess as result of focal infection, 

497 
Brass, composition and uses of, 612 
poisoning, symptoms of, 612 
treatment of, 613 
Break-bone fever. See Dengue. 
Breakfasts, examples of, 319 
Breathing exercises, 501 
Bronchitis as cause of infant death, 831 
Bronchopneumonia, preventive measures, 

86 
Budget, health, 237-238 

rural, 564 
Buildings, inspection of, by health 

officers, 561 
BuUetins, health, 746-747 

distribution of, 747 
Burns, acid, in munition manufacture, 

626 
Butter, adulteration of, 345-346 
effect of cold storage upon, 332 



Calcium hypochlorite disinfection of 

swimming pools, 463-464 
Calcutta, Black Hole of, 239 
Caloric values of foods, 309-313 
Calor3 r , the unit of heat, 308 
Camp, hygiene of, 541 

preparation of food in, 524 

site, change of, 533 
occupation of, 533 
selection of, 533 

time devoted to exercise, 524 
Camps, concentration. 531 

medical sendee in, 548 

mobilization, 531 
Candy, use of sulphurous acid in, 339 
Cantonments, waste disposal in, 439-442 



864 



INDEX 



Carbohydrate foods, 309 
C Sarbolic acid solution as disinfectant, 186 
Carbon bisulphide poisoning, symptoms 
of, 613 
treatment of, 614 
uses of, 613 
dioxide, 240-241, 242 

determination of, 282-283 
physiological effects of, 243-244 
poisoning, symptoms and treat- 
ment of, 614 
production of, in industry, 614 
relation of, to ventilation, 280 
standards, 261-263 
use of, in food preservation, 340 
monoxide poisoning, acute, symp- 
toms of, 614 
treatment of, 615 
chronic, symptoms and 

treatment of, 615 
prevalence of, 614 
Carbonic acid in water, 414 
Cargo, dangers of, in maritime quaran- 
^ tine, 800 
Carriages, ambulances, disinfection of, 193 
Carriers, diphtheria, 102 
germ, 24-25 
human, 24 
lower animals, 25 
typhoid fever, 133-134 
Cars, methods of cleaning and disinfect- 
ing, 191 
Cassion disease. See Compressed air 

illness. 
Cells, phagocytic, 49-50 
Census, 809 

errors in, 809-811 
Cerebrospinal meningitis, incidence of, 97 
incubation period of, 97 . 
infective agent of, 97 
methods of control of, 97-98 
mode of transmission of, 97 
period of communicability of, 97 
relation of, to feeble-minded- 

ness, 788 
source of infection of, 97 
Cess-pools, methods of cleaning and dis- 
infection, 191 
Chancroid, 149 

Charities and sanitary survey, 235 
Charts, rules for preparation of, 855-858 
Chemical precipitation of sewage, 431 
Chemicals, antiparasitic action of, 177 
Chest measurement of recruit, 520 
Chickenpox, incidence of, 124 
incubation period of, 124 
infectious agent of, 124 
methods of control of, 124 
mode of transmission of, 124 
period of communicability of, 124 
source of infection of, 124 
Child hygiene, 668-722 

bureau organization, 668-669 
care of abandoned and illegiti- 
mate children, 695-697 
duties of health officer, 561 



Child hygiene, examination of children 
for physical defects, 708-715 
functions of bureau of, 669 
hygiene of home, relation to, 

714-715 
public health nurse and, 574 
scope of, 668 

supervision of child of pre- 
school age, 697-700 
Children, feeding of, 487 

mental training of, 770 
Chlorinating apparatus, 421 
Chlorine in disinfection of swimming 
pools, 463-464 
in purification of water in field, 424 
in sterilization of sewage, 435 

of water, 420 
in water, 412-413 
Chloro-pump, 426 

Chokes. See Compressed air illness. 
Cholera, incubation period of, 142 

infection from raw vegetables, 393 
infective agent of, 141 
methods of control of, 142-143 
mode of transmission of, 142 
period of communicability of, 142 
quarantinable disease, 798 
source of infection of, 142 
in tropics, 598 
water-borne, 407, 417 
Chronic disease, factors influencing, 472 
increase in mortality rates, 
478 
Cleanliness, personal, 502 
Cleansing and disinfection, agents for, in 
house and sickroom, 186 
methods in homes and public 
places, 191 
Climate, 583 

classification of, 583 
Clinic facilities, effect of, on mortality 

rate, 828 
Clothing, 506-507 

improper, as factor influencing phys- 
ical deterioration, 472 
of recruit, list of, 522-523 
of soldier, 522-523 
tropical, 586 
Coagulation in water purification, 418 
Cold storage, 331 T 332 
Colloids, flocculation of, 33 
Colon bacillus in cerebrospinal menin- 
gitis, 97 
in water, 416-417 

presumptive tests for, 416 
significance of, number of, 
416 
Combat, medical service in, 549 
Comfort zone, 255-256 
Committee on standard methods for ex- 
amination of air, 280, 282-283 
Common colds among soldiers, 551 
Communicable disease, overcrowding 
and, 297 
public health nurse and, 574 
reports, use of, 847 



INDEX 



865 



Communicable disease, source of infec- 
tion, importance of, 
207 
proof of, 210 
in camps, 531 

duties of health officers, 559 
factor influencing physical de- 
terioration, 473 
isolation by physician, 569 
reporting of, 846 

by physician, 568 
soil pollution in tropics and, 595 
types of outbreaks, 208-210 
Complement, 45-46 
Complement-fixation reaction, 47-49 
application of, 48-49 
to identify antibodies in pa- 
tient's serum, 48 
unknown microorganisms, 

, 48 . 
quantitative determination of 

complement-fixing antibodies 
in serums, 49 
Complexion, care of, 505 
Compressed air illness, 615 

prevention and treatment 

of, 617 
symptoms and prevention 
of, 616 
sensations under compression, 
616 
Congenital diseases as cause of infant 

death, £78, 833 
Conjunctivitis, acute infectious, incuba- 
tion period of, 87 
infectious agent of, 87 
methods of control of, 87 
mode of transmission of, 

87 
source of infection of, 87 
treatment of, in school children, 707 
Consanguinity, relation of, to feeble- 
mindedness, 788-789 
Constipation, 507-509 

as result of unbalanced diet, 320 
Consumption, grinders', 259 
Contact as factor in health, 556 
Contagious diseases, 216 

control of, in schools, 705-706 
epidemiology of, 216-218 
influence of, upon infant mor- 
tality, 680 
Cookers, tireless, 323 
Cooking, changes wrought in food by, 
322 
importance of, 317 
methods of, 323 
utensils, 323 . 
Copper sulphate in disinfection of swim- 
ming pools, 463 
use of, in sterilization of water, 
423 
Corral, sanitation of, 541 
Crampton index, 249 
Cresols as disinfectants in house and 
sickroom, 188 
55 



Cubic space, allowance of, for ventilation 

261-262 
Cuspidors in industrial plants, 652 

methods of cleaning and disinfect- 
ing, 191 
Cysticercus, 394, 396 



Dairy inspection, duties of health officer, 

560 
Dandruff, prevention of, 505 
Day nurseries, 698-700 
Dead, disposal of, on battlefield, 545 
Death, cause of, unsatisfactory terms 
used, 837-842 
certificates, errors in, 836 
cause of, 837 

correction of, 837-843 
international classification of causes 

of, 843-845 
rate and sanitary surveys, 225-226 
crude, 823 
definition of, 821 
factors affecting, 826-833 
monthly, 823 
quarterly, 826 
rural and urban, 555 
specific, 826 

and standardized, 852-854 
weekly, 823 
Deaths, reports of, by attending physi- 
cian, 570 
statistics of, 820-833 
Defectives, mental. See Mental defec- 
tives. 
Dementia precox, 763-764 
Dengue, incidence of, 172 
incubation period of, 172 
infectious agent of, 1-72 
methods of control of, 172 
mode of transmission of, 172 
mosquito and, 592 
period of communicability of, 172 
source of infection of, 172 
Dentists in the army, 546 
Deodorants, 177 
Desensitization, 61 

Diabetes as result of focal infection, 497 
Diagrams, use of, in epidemiology, 220 
Diarrhea among soldiers, 531 

cause of infant death, 831-833 
in infants, influence of temperature 
on, 349-350, 355-356, 362 
relation of water supply to, 407 
oysters and, 390 
Diarrheal diseases, influence of, on infant 

mortality, 678-680 
Diet, correct, principles of, 479-482 
excessive, results of, 319 
for children, 487 

for overweight, suggestions, 483-487 
fruit and vegetables, 318 
insufficient, 320 
need of mixed, 320 



866 



INDEX 






Diet, public instruction on, 479-482 
salts in, 321 
unbalanced, 320 
Dietary diseases, 320 
Diphtheria, 100-114 

active immunity produced by injec- 
tion of diphtheria toxin, 109 
immunization, duration of im- 
munity, 112 
bacilli in milk, 383 
bactericidal and antitoxic immunity, 

112 
carriers of, 101-102 
immunity produced by, 100 
incidence of, 100 
individual susceptibility to, 100 
infecting agent of, 101 
mode of transmission of, 101 
N. Y. City Health Department Cir- 
cular on, 114 
period of communicability of, 101 
prevention of, 101-114 

antitoxin in, 102 
production of lesions in, 100 
reactions following the use of toxin- 
antitoxin in, 1 13 
reduction of death-rate in, by use of 

antitoxin, 102 
Schick reaction. See Schick reac- 
tion, 
source of infection of, 101 
susceptibility to, according to age, 

106-107 
suspected cases of, with negative 

Schick reaction, 108 
time required to produce active 

immunization, 111 
toxin, use of, in Schick reaction, 105 
toxin-antitoxin, 109 
dose of, 110-111 
Dirt testers, 372 
Disease, causes of, 472 

diagnosis of, by means of agglutina- 
tion reaction, 37 
dietary in, 320 
dissemination of, 23-25 
effect of temperature upon, 253-255 

of ventilation upon, 274-276 
etiologic factors, 724 
infectious, susceptibility to, 211-213 
insects in tropics and, 589-595 
mental attitude as cause of, 517-518 
occupational and industrial, 604 
sociologic and economic aspect of, 

723 
water-borne, relation of polluted 

water to, 407-409 
worry and, 517 
Diseases, chronic, increase in mortality 
rate, 478 
communicable, duties of health 
officer, 559 
reports of physicians, 568 
individual infectious, prevention of, 

73-176, 859 
infectious, classification of, 216 



Diseases, occupational, 608 
classification of, 608 
occurring in man and lower animals, 
215 
only in man, 215 
quarantinable, 798 
of soldier, 551 

transmitted from lower animals to 
man, 215 
through swimming in polluted 
water, 459-460 
Disinfectants and methods of disinfect- 
ing in house and sickroom, 185- 
191 
antiseptic value of, 182 
choice of, 185 
determination of germicidal action 

of, 178-179 
penetration of, 184-185 
practical use of, 177-200 
standardization of, 179-183 
Disinfecting chambers, steam, 196-197 
Disinfection and cleansing, agents for, 
186-188 
of bodily discharges, 189 
of body after death, 190 
of books, 192-193 
of carriages, ambulances, etc., 193 
in epidemic fighting, 222 
of food and drink, 189 
gas, control of, 184 
of hands and person, 188 
of house with sulphur dioxide, 195 
incomplete, by chemicals, 177 
of linen, 189 
in maritime quarantine practice, 

801-804 
method of, in house and sickroom, 

185-191 
methods to be used in homes and 

public places, 191 
of nursing bottles, 200 
practical application of, 184 
in presence of albuminous matter, 

185 
of rags, 190 
of rooms, 190 
surgical, 197 
of table utensils, 190 
of tents, 532 
terminal, 184 
time as a factor, 185 
of water in swimming pools, 463-467 
Dispensaries as educational centers, 754 
role of, in mental hygiene, 776-777 
Draft, U. S. Army, results of physical 

examination in, 475-477 
Drafts, exposure to, 499 

in industrial plants, 631 
Dressing stations, 547 
Dreyer method of macroscopic agglu- 
tination, 40-41 
Drinking fountains in industrial plants, 

648 
Drying, effect on infectious organisms, 24 
food, preservation by means of, 331 



INDEX 



867 



Duodenal ulcer as result of focal infec- ' 

tion, 497 
Dust in air, 241-242 

enumeration of particles, 290 
bacterial content of. 257-258 
determination of, 290-291 
elimination of, in industry, 631 
harmful effects of, 259 
house, 499 
mineral, 259 
typhoid fever and, 133 
Dwellings, types of, 445-446 
Dysentery, amebic, incidence of, 140 
incubation period of, 141 
infective agent of, 141 
method of control of, 141 
mode of transmission of, 141 
period of communicability of, 

141 
source of infection of, 141 
in tropics, 597 
bacillary and amebic, differential 
diagnosis of, 141 
incidence of, 139 
incubation period of, 140 
infective agent of, 140 
methods of control of, 140 
mode of transmission of, 140 
period of communicability of, 

140 
source of infection of, 140 
in tropics, 597 
from raw vegetables, 393 
oj-sters and, 390 
privy and, 428 
soldier and, 551 
transmitted by means of swimming 

pool, 459 
in tropics, caused by irritants, 597 
water-borne, 407, 417 



E 



Ear diseases transmitted by means of , 

swimming pools, 460 
Echinococcus, 394 

Economic conditions, effect of, on mor- 
tality rate, 828 
factors as causative agents in dis- 
ease, classification of, 724 
Eczema as result of unbalanced diet, 320 
Edema, war. 325 

relation of, to diet, 735 
Education and proper housing condi- 
tions, 307 
in epidemic fighting, 221 
public health, 735-756 

duties of health officer, 561 
in personal hvgiene, 471. 

474, 480 
in reduction of infant mor- 
tality. 693-694 
in rural public health work. 577-579 
sanitary surveys and, 236 



Education in venereal disease prevention, 

152 
Educational methods in industrial hy- 
giene, 606 
Efficiency, effect of temperature upon, 

250-253 
Eggs, adulteration of. 344-345 

candling, 393 

as cause of disease, 393 

cold storage, 332 

dried, 393 
Ehrlich, side chain theory, 27-29 
Electricity for illuminaaon, 451-452 

use of, in food preservation, 340 
Emigration, effect of, on mortalitv-rate, 

829 
Encephalitis lethargica, 859 
Endemic, 208 
Endo-enzymes, 52 
Endolysins, 52 
Entameba buccalis, 512 
Enteritidis, bacillus, 390, 391 
Environment as factor in health, 555-556 

hygiene of, 627-665 

influence of, on living, 304-306 
Enzymes, 71-72 

of host, 71 

microbal. 71 
Epidemic, 209 

fighting of, 221-223 

parotitis. See Mumps. 

roseola. See German measles. 
Epidemics, control of. 206 

milk, detection of, 389-390 

types of, 208 
Epidemiologists, 205-206 
Epidemiology, 201-223 

conception of cause of, 206-208 

definition of, 201 

function of, prophecy of, 204-205 

knowledge of, necessary. 202 

methods and resources of, 202-203 

objects of, 203-204 

proof of, source of infection, 210-211 

tabulations and graphs of, 219-221 
Ergotism, 394 

Eugenics and heredity. 766-767 
Evacuation points, 548 
Excreta, disposal of, in camp, 541-543 
Exercise, 514-516 

breathing, 501 

for soldiers. 524-525 

provision for, on troop transports, 
530 
Exhaust sj'stem of ventilation, 634-635 
Exhibits, public health, 578 

use of, in public health education, 
748-750 
Explosives, local irritant effects, 627 
Eve diseases, contagious, control of, in 
schools, 706-708 
transmitted through swimming 
pools, 460 
Eyes, care of, 513-514 

scarring of cornea from industrial 
accidents, 641 



868 



INDEX 



Factories, temperature of, 285 
Factory lighting, 637-644 

windows, arrangement and con- 
struction of, 639-640 
Fairfield system of ventilation, 266-268 
Fan ventilation, 268-276 
Fat content of milk, determination of, 
364 
foods, 310, 480 
Favus, 173 

treatment of, in school children, 707 
Feces, bacteriologic examination of, in 
typhoid fever, 135 
disinfection of, 189 
Feeble vitality as cause of infant mor- 
tality, 678 
Feeble-minded persons, treatment of, 791 
Feeble-mindedness, economic aspect, 790 
mental characteristics in, 790 
in reformatories and prisons, 790 
relation to crime, 791 
Feet, care of, by soldiers, 526 
flat, 510 
weak, 509 
Ferments, 71 
Ferry boats, methods of cleaning and 

disinfecting, 191 
Field hospital company, 547 
Filaria and the mosquito, 592 
Filters, contact or biological, in sewage 
treatment, 433 
for swimming pools, 461 
mechanical, 419-420 
pressure, 420 
slow sand, 418-419 
sprinkling, 433-434 
water, for troops, 539-540 
Filtration of sewage, intermittent sand, 
434 
of water, 418-420 
Finger-nails, care of, 506 
Fire hazards in industrial plants, 664 

method of studying, 
231 
First aid in industrial plants, 660, 663 

packet, 530, 546 
Fish, adulteration of, 344 

effect of refrigeration and cold stor- 
age on, 332 
parasitic organisms and, 396 
pathogenic bacteria in, 390 
Flat foot, 510 
Fleas, 591 

Flies and typhoid fever, 133 
Fluorides/detection of, in food, 337-338 

use of, as food preservatives, 337 
Fluorine, a food constituent. 328, 329 
Fly breeding and sanitary survey, 236 
destruction of breeding places of, 

448 
disseminator of disease in tropics,594 
house, 593 

life history of, 439 
nuisance, checking of, 439 



Fly, sand, relation of, to tropical diseases, 
593 

screening against, 448 
Food, 308-323 

accessory factors, 324 

adulteration of, 341-346 

and drink, disinfection of, 189 

breakfasts, examples of, 319 

calories required at different periods 
of life, 482 

changes wrought by cooking, 322 

cooking of, for soldiers, 531, 535 

daily individual requirements of, 311 

deficiency of, as factor influencing 
physical deterioration, 472 

duties of health officer, 560 

eating in industrial plants, 653 

economics, 313 

effect of excessive amounts of, 319 

excess of, as factor influencing physi- 
cal deterioration, 472 

fluorine a constituent of, 328, 329 

hormones, 324 

importance of, to health, 308 

need of mixed diet, 320 

poisoning, Botulismus, 392 

precaution necessary in tropics, 586 

preparation of, 317 
of camp, 524 

preservation of, natural methods, 
328 
physical and chemical methods, 
330-331 

preservatives, table of relative anti- 
septic values, 329-330 

in rail transportation of troops, 528 

relation of, to personal hygiene, 473 

salt a constituent of, 328-329 

selection of, 317 

source of bodily energy, 308 

unbalanced diet, 320 

value of thorough mastication, 482 

vehicle of infection, 218 
Foods, antiscorbutic, 326 

building and repair, 480 

carbohydrate, 309 

classification of, 585 

cooking of, 317 

fat, 310 

fresh, importance of, 326 

fruit and vegetables, 318 

fuel, 480 

insufficient diet, 320 

nutrient and fuel needs of body, 310 

poisoning from meat, 393 
from plants, 393 

preservation of, 328-340 

protein, 310 

regulating of, 481 

supplemental, 311 

vitamine content of, 325, 326 
Foodstuffs as fuel, 309 
Foot-and-mouth disease, 321 

following vaccination, 122 
Formaldehyde in food, 329 

gas in disinfection of vessels, 803 



INDEX 



869 



Formaldehyde gas, methods of provid- 
ing, 193 
practical employment of, for 

disinfection, 191 
vs. sulphur dioxide for disinfec- 
tion, 196 
in milk, 348 

detection of, 364 
use of, as a food preservative, 336 
Formalin as disinfectant in house and 

sickroom, 188 
Formic acid, use of, as food preservative, 

338 
Friedlander's bacillus in acute lobar 

pneumonia, 85 
Fruit and typhoid fever, 133 
as part of dietary, 318 
canned, adulteration of, 345, 346 
dried, use of sulphurous acid in, 
339 
Fumes, poisonous, in air, 259 
Fungi causing infectious cutaneous dis- 
eases. See Skin diseases. 



Garbage, collection of, 436-437 
disposal of, 437-439 
in camp, 541 
sanitary survey and, 234 
economic waste in, 438 
feeding of, to swine, 438 
Gas, acetylene, for illumination, 451 
attacks, hygiene of, 543-545 
illuminating, dangers of, 450 
naphtha, for illumination, 450-451 
oil, for illumination, 451 
sewer, 458 

types of, used in warfare, 544 
Gastric ulcer as result of focal infection, 

497 
General paralysis, 758-759 
deaths from, 759 
frequency of, 758-759 
hereditary syphilis and, 759 
German measles, incubation period of, 127 
infectious agent of, 126 
methods of control of, 127 
mode of transmission of, 126 
period of communicability of, 

127 
source of infection of, 126 
Germicides in milk, 348 
Glanders, bacillus of, in cerebrospinal 
meningitis, 97 
incidence of, 168 
incubation period of, 169 
infectious agent of, 168 
meat inspection for, 321 
methods of control of, 169 
mode of transmission of, 169 
period of communicability of, 169 
source of infection of, 168 
Gonococcus in acute infectious conjunc- 
tivitis, 87 
in cerebrospinal meningitis, 97 



Gonorrhea as cause of death, 843 
incidence of, 147-148 
incubation period of, 148 
infectious agent of, 148 
methods of control of, 148, 149-153 
mode of transmission of, 148 
period of communicability of, 148 
source of infection of, 148 

Gout as result of unbalanced diet, 320 

Graphic presentations of vital statistics, 
854-858 

Graphs in epidemiology, use of, 220-221 

Great Britain, Depaitmental Reports on 
Ventilation, 248, 262, 263, 265, 272 

Grit chambers, 431 

Ground water, 404-406 



Hands as vehicles of infection, 219 
Hats, relation of, to personal hygiene, 

507 
Health and lay societies, 571 

board, rural, duties of, 564-567 
organization of, 557 
source of powers of, 557 
bulletins, 744 

distribution of, 745 
centers in hygiene of child of pre- 
school age, 698 
department and sanitary survey, 237 
inspectors, activities of, in rural 

districts, 572 
physician and, 567-571 
relation of, to housing, 300-304 
reports and records of, 579-581 
hazards in factories, method of 
studying, 231-232 
in industry, warning workers 
of, 658-359 
insurance, 604 

officer, activities of, in rural com- 
munities, 558-562 
education of, for rural health 

work, 558 
importance of vital statistics to, 

806 
investigations by, 562 
newspaper editor and, 746 
notification by, 563 
procedures by, 562-564 
public health education in 

schools and, 739 
reports and records of, 579-581 

of investigations, 580 
rural, 557-564 
status of, 582 
public, nurse, 572-573 
relation of atmospheric conditions 

to, 239-261 
work, control of, environmental fac- 
tors, 555-556 
rural, 555-582 

education in, 577-579 
publicity in ? 577-579 



870 



INDEX 



Heart disease as result of focal infection, 

197 
Heat as disinfectant in house ami sick- 
room, 186 
preservation of food by, 332-333 
stroke. 248-249 
Beating and ventilation, 263-265 

industrial plants, 636-637 
Height and weight, average, tables of, 
486 
of recruit, 520 
1 [ellebore, use of, in checking fly nuisance, 

439 
Heredity and eugenics, 766-767 

as a factor influencing physical de- 
terioration, 472 
relation to feeble-mindedness, 788 
to mental disease, 762 
Hodgkins disease as result of focal infec- 
tion, 497 
Hogs and parasitic organisms, 394-396 
Hookworm disease, incidence of, 175 
incubation period of, 176 
infectious agent of, 176 
methods of control of, 176 
mode of transmission of, 176 
period of communicability of, 

176 
privy and, 428 
source of infection of, 176 
in tropics, 595 
Hormone deficiency as factor influencing 

physical deterioration. 472 
Hospital and dispensary facilities, effect 
of, on mortality rate, 828 
ventilation, 266, 274 
Houses, tropical, site and construction 
of, 587 
ventilation and drainage of, 588 
Housing, 293-307, 443-458 
building material, 447-448 
conditions and sanitary survey of, 

232-233 
effects of overcrowding on, 297 
essential requirements of healthful 

private dwelling, 446-458 
good, its achievement, 306-307 
heating, 449 

influence of environment, 304-306 
legislation, 306-307 
lighting, 449-452 
location and site, 446 
1>1 umbing, 452-455 
privy vaults and, 297-299 
problem, 443-445 
regulations, 444 

relation of health department to, 
: 100-304 
to infectious disease, 294 
to tuberculosis, 294-295 
rooms, arrangement of, 448-449 

size of, 449 
screening, 148-449 
sewerage or drainage, 455-458 
soil, 146 1 17 
tuberculosis and, 1 1 1 



Housing, venereal disease and, 300 
ventilation and, 296-297, 448-449 
water supply, 299, 452, 453 
Ilumidification, 269-271 
Humidity. See also Relative humidity, 
and temperature, effect upon effi- 
ciency, 250 
physiological effects of, 246-250 
Hydrocephalus, 780-781 
Hydrocyanic acid gas in disinfection of 
vessels, 803 
in food, 329 
Hydrogen peroxide as a food preserva- 
tive, 330 
Hydrophobia. See Rabies. 
Hygiene of environment, 627, 665 

industrial. See Industrial hygiene, 
mental. See Mental hygiene, 
personal, 499-518. See also Per- 
sonal hygiene, 
tropical, 583-601 
Hypersensitiveness, 58-70 
infection and, 69 
in man, 65-69 

allergy to foods, pollens, etc., 68 

collapse, 66 

death, 66 

desensitization to serum, 67 

drug allergy, 68-69 

idiosyncrasy, 68-69 

local reactions, 67 

serum reaction, 66 

prevention of, 67-68 
sickness, 66-67 
treatment of developed shock, 
68 
immunity and, 70 
toxin, 64-65 
Hysteria, 764 



Ice, relation of, to transmission of water- 
borne disease, 408 
Ice-borne typhoid fever, 131-132 
Ice-box for milk in the home, 361 
Idiosyncrasy, 68-69 
Idiots, 783 

Illegitimacy, effect of, on infant mor- 
tality, 831 
Illegitimate children, care of, 695-697 
Illuminants, effects of, on atmosphere, 

262-263 
Imbeciles, 783, 789 
Imhoff tank, 432-433 
Immigration, effect of, on mortality rate, 
829 
role of, in mental hygiene, 778 
Immunity, antiblastic, 72 

conveyed by certain diseases, 215 
hypersensitiveness and, 70 
Impetigo, treatment of, in school chil- 
dren, 707 
Incineration in disposal of waste, 437-438 
Incinerator for human excreta, 543 
Palmer, 440-442 






IXDEX 



871 



Incubation period in infectious diseases. 

222-223 
Industrial accidents to eyes, 641-642 
dust and fumes, 259 
hygiene, 602-667 

educational methods, 606 
financial loss through illness, 603 
importance of, 602-603 
inspection, 605 
laws, 605 

medical supervision, 665-667 
occupational disease and. 604 
periodic medical examination. 

605-606 
scope of, 605-608 
statistical data, 607 
plants, drinking cups and water sup- 
ply, 647-649 
fire hazards, 664-665 
heating, 636-637 
lockers for clothes, 646-647 
lunch and rest periods, 653-654 
lunch-rooms, 653 
spitting and cuspidors, 651-653 
sweeping and cleaning, 650-651 
toilets, 650 

towel supply, 649-650 
washing facilities, necessity for. 
645-646 
Industries and sanitary surveys. 231-232 
Industry, effect of alcoholism on, 657-65b 
of monotonous work on, 654 
instruction in safetv measures and 

first aid, 660-661* 
medical examination of emplovees. 

666 
physical strain, 655-657 
safety devices,' 661-662 
speeding up and overtime work, 654 
warning workers of hazards, 658- 
659 
Infancy, mental training in, 768-769 
Infant deaths, immediate causes, 831-833 
feeding, age and results, 359 
mortality, 671-694 

accidents of labor as cause of, 

678 
alcoholism as cause of. 678 
among illegitimate, 732 
atmospheric temperature and, 

253 
in Calcutta, 728 
causes of, 674 
definition of, 671-672 
distribution, of in U. S. by 

causes, 678 
economic conditions in relation 

to, 676-677 
effect of babv health stations 
on, 690 
of illegitimacy on, 677 
of immigration on, 675 
of institutionalism on, 695 
of maternal employment 

on, 677 
on mortality rate, 830 



Infant mortality, effect of nativity of 

mother on, 675 
of overcrowding on, 674 
of unhygienic conditions 
on, 675 
environmental causes of, 674 
factors affecting, 831-833 
feeble vitality as a cause, 678 
hot weather and, 729-730 
influence of, on birth rate, 817 
of congenital diseases on, 

678 
of contagious diseases on, 

680 
of diarrheal diseases on, 

678-680 
of improper milk supply 

on, 679 
of respiratorv disease on, 

680 
of type of feeding on, 688 
in Xew Zealand, 728 
prematuritv as a cause, 678 
problem of, 672-674 
reduction of, 680-694 
auxiliary aids, 694 
community program in, 680 
by conferences of mothers, 

'691 
effect of public health, 

education, 693-694 
by home visits of nurses, 

690-691 
individual program in, 681 
by Little Mothers' League. 

691-693 
by prenatal work, 682-683 
relation of, to age of mother, 
731 
to attendance at birth, 731 
to birth-rate. 730-731 
to income, 729, 733-734 
to nativity of mother, 731 
to prenatal care of mothers, 

732-733 
to price of milk, 730 
to race, 731-732 
to type of feeding, 728-729 
in Russia, 728 
sanitary surveys and, 227-229 
social and economic aspects of. 

728-734 
in United States, 728 
Infantile paralysis. See Poliomyelitis. 
Infants, boarding of, regulations govern- 
ing, 696-697 
requirements of, for permit, 695 
diarrhea in, influence of temperature 
and bacteria. 349, 355, 362 
relation of, to water supply, 407 
illness caused by milk from im- 
properly fed cows, 348 
proportion of, consuming cows' milk, 
360 
Infected water, 406 
Infection, hypersensitiveness and, 69 



872 



INDEX 



Infection, influence of quantity of micro- 
organisms on, 19 
mixed, 20-21 
secondary, 20-21 

symptoms of, and anaphylaxis, 64 
two main elements of, 211-213 
Infections, bacterial and parasitic, as 
factors influencing physical dete- 
rioration, 473 
focal, 496-498 
interrelation of, 214 r 216 
Infectious diseases, classification of, 216 
incubation period of, 222-223 
portal of entry of, 213-214 
prevention of, 73-176, 859 
transmission of, 223 
material, common vehicles of, 218 
manner of leaving the body, 24 
Influenza, 73-85 

bacillus in cerebrospinal meningitis, 

97 
bacteriology of 1918 epidemic, 84 
incidence of, 73 
ordinary colds and, 74 
overcrowding and, 297 
prevention of, 74 

administrative procedures, 76 
education and publicity, 76 
organization, 76 
relief measures, 79-84 
vaccines in, 74, 84-85 
Insane, treatment of, 777-778 
Insanity, increase of, 765 
manic-depressive, 764 
Insecticides, 177 

Insects, disease in tropics and, 589, 590 
stinging in tropics, 591 
vehicles of infection, 219 
Insomnia, 516 

Inspection in epidemic fighting, 222 
Inspectors, rural health, activities of, 572 
Insurance, health or sickness, 604 
Intelligence quotient in mental defi- 
ciency, 783-784 
Intestinal infections, epidemiology of , 217 
Intestines, entrance and growth of micro- 
organisms in, 22-23 
Investigation in epidemic fighting, 222 
Investigations, reports of health officer, 

580 
Iron in water and its removal, 414 
Isolation in epidemic fighting, 221 



Katathermometer, 248, 288-290 
Kefir, 340 

Kidney disease as result of focal infec- 
tion, 497 
King system of ventilation, 267 
Kitchen cars, 528 
Kitchens, inspection of, 536 

portable, 535 
Korsakoff psychosis, 759 
Koumis, 340* 



Labarraque's solution, disinfectant in 

house and sickroom, 188 
Labor, accidents of, cause of infant mor- 
tality, 678 
Laboratory, public health, activities of, 
575-577 
and sanitary surveys, 235 
use of, by health officer, 
559 
Lactic acid, use of, as food preservative, 

340 
Lakes as sources of water supplies, 404 
Latrines, 455 

for permanent camps, 542 
for trenches, 543 
Law, cold storage, 332 

governing swimming pools, 468 
Mosaic, 736 

pure food and drugs act, 341-343 
relating to industrial hygiene, 605 
statute, as a source of power in 

health work, 557 
vaccination, 119 
Lay organizations in rural health work, 
557 
societies and public health, 571-572 
Lead poisoning, mode of entrance of, 618 
prevention of, 621 
symptoms of, 619-621 
treatment of, 622 
uses of, in industry, 617-618 
in water, 414 
Lectures in public health education, 

750-751 
Legal actions by health officer, 562-564 
Legality of milk regulations, 372 
Legislation, housing, 306-307 
Leprosy, incidence of, 95-96 
incubation period of, 96 
infectious agent of, 96 
methods of control of, 96 
mode of transmission of, 96 
period of communicability of, 96 
quarantinable disease of, 798 
source of infection of, 96 
Leukoprotease, 52 
Lice, destruction of, 591 

soldiers infested with, 524 
Light, artificial, in houses, 449-452 

effect of, on infectious microorgan- 
isms, 24 
on vision, 513-514 
necessity for, in houses, etc., 499 
Lighting, artificial, in industrial plants, 
facts as to, 643-644 
of factory, 637-644 
in industry, effect of paint and 

cleanliness on, 642-643 
of schools, 717 
Lights, bright, effect of, 640-641 
Lime, chlorinated, as disinfectant in 
house and sickroom, 188 
milk of, as disinfectant in house and 
sickroom, 187-188 



INDEX 



873 



Linen, disinfection of, 189 
Little Mothers" League, 691-693 
Lock-jaw. See Tetanus. 
Londonderry, catastrophe on, 240 
Lung block, New York City, 444 
Lungs, entrance and growth of micro- 
organisms in, 22 
Lyster bag, 426 



M 



Malaria, economic aspect of, 734 
incidence of, 155 
incubation period of, 155 
infectious agent of, 155 
methods of control of, 155-156 
mode of transmission of, 155 
mosquito and, 592 
period of communicability of, 155 
quinine prophylaxis in, 155 
source of infection of. 155 
Malignant pustule. See Anthrax. 
Manic-depressive insanity, 764 
Manure, disposal of. 438 

in cantonments, 440 
Maps, pin. 854 
Marasmus as result of unbalanced diet, 

320 
March, medical service on, 548 
Marching of troops at night, 527 

rate of, 526 
Marital condition, effect of, on mor- 
tality rate, 827-828 
state and mental hygiene. 774-775 
Maritime quarantine. 795-804 
history of. 795-796 
types of vessels met with. 796 
Markets, sanitation of, and sanitarv 

surveys, 233-234 
Marriage rate, calculation of, 813 
factors influencing, 812 
statistics. 811-813 
legal uses of, 812 
Masturbation, relation of, to mental dis- 
ease, 772 
Maternity centers, 682-683 
Matzoon, 340 
Measles in camps, 531 
incidence of, 125 
incubation period of, 125 
infectious agent of. 125 
methods of control of, 125-126 
mode of transmission of, 125 
period of communicabnity of, 125 
source of infection of, 125 
Meat, adulteration of, 344 

effect of refrigeration and cold 

storage on, 332 
inspection of, 321-322 
parasitic organisms and, 394-396 
pathogenic bacteria in, 390 
poisoning, 390-393 

Botulismus, 391-392 
tapeworm and, 396 
tuberculosis and, 390 
use of sulphurous acid on, 339 



Mechanical filters, 419-420 

milker, 372 
Medical examination, causes of rejection 
in draft, 476 
in navy and marine 
corps. 477 
of employees in industrial 

plants, 666 
periodic. See Periodic Medical 
examinations, 
in industrial hygiene, 605 
results of. in certain groups, 

474-47S 
of school children, 739 
inspection of school children. See 
School, Medical Inspec- 
tion, 
and public health nurse, 
574-575 
school inspection and sanitary sur- 
veys, 234-235 
sendee in camp, 548 
in combat, 549 
during retreat, 550 
on march, 548 
Meningitis, cerebrospinal. See Cerebro- 
spinal meningitis. 
Meningococcus in cerebrospinal menin- 
gitis, 97 
Mental age, determination of, 784-790 
apathy, as factor influencing physi- 
cal deterioration, 472 
characteristics in feeble-minded, 790 
defectiveness, solution of the prob- 
lem, 792 
defectives, prevalence of, 780 

preventing and controlling 
measures. 780-794 
deficiency, 782-783 
disease among soldiers, 551 
constitutional. 762-767 
due to tissue changes, 758-761 
disorders due to alcohol, 759-761 
hygiene. 757-779 

in adult, 772-774 
general measures in, 775-778 
marital state and, 774-775 
school and, 771 
training in infancy, 768-769 
of older children, 770 
at puberty. 771-772 
work, effect of temperature on, 251 
Mentality, determination of, 784-790 

of soldiers, 521 
Mercury poisoning, prevention and 
treatment of, 623 
symptoms of, 622-623 
uses of, in industry, 622 
Meteorology. 583 

Methyl alcohol in food preservation, 334 
Microbal auto-infection, 25 
enzymes, 71 
poisons, 26 
Microbes, adaptation of, to soil, 19 

tissue characteristics influencing 
entrance and growth of, 21-23 



i 



874 



INDEX 



Microcephalia, 781-782 
Microorganisms, growth of, outside in- 
fected tissues, 24 
identification of, by agglutination 
reaction, 36-37 
complement-fixation reaction, 48 
increase and decrease of toxicity of, 
20 
of virulence of, 20 
influence of quantity of, on infec- 
tion, 19 
manner of producing injury, 19 
point of entry of, importance of, 23 
relation of, to disease, 17-31 
resistance of, 24 

variation and degree of virulence of, 
19-20 
Midges, 593 

Midwives, control and supervision of, 670 
ophthalmia neonatorum and, 670. 
puerperal septicemia and, 671 
Mikvehs, Jewish ritual baths, 467-468 
Miles' acid process, 432 
Military hygiene, 519-554 
exercises, 524-525 
general sanitation, 540-543 
movement of troops, 525^527 
the recruit. See Recruit, 
scope of, 519 
service, results of physical examina- 
tions for, 475-477 
Milk, adulteration of, 344, 348-349 
bacteria in, growth of, 349 
identification of, 383 
pathogenic, 385-390 
bacterial and other contaminations 

of, 347-384 
bacteriological examination of, 383 
boric acid in, 337 

borne disease, relation of bacteria to, 
349-363 
typhoid fever, 132,134 
bottled, bacteria in, 354 

best, effect on infants, 358-359 
effect on infants, 356 
care of nursing bottles, 200 
certified, 374-380 
chemicals added to, from containers, 

348 
condensed, effect of, on infants, 356 
conveyor of diphtheria, 101 

of tuberculosis, 91 
cows', proportion of infants con- 
suming, 360 
deleterious substances in, due to 

improper feeding of cows, 348 
detection of adulteration of, 364 

of formaldehyde in, 336 
determination of fat content, 364 

of total solids, 364 
diseases transmitted by, 385 
dry, 382-383 

duties of rural health officer, 560 
effect of improper supply on infant | 

mortality, 679 
epidemics, detection of, 389-390 



Milk, germicides in, 348 

grading of, advantages of, 374 

regulations covering its sale, 370 
infection, relation of typhoid carrier 

to, 388-389 
pasteurization of. See also Pas- 
teurization of milk, 
in the home, 199-200 
price of, relation of, to infant mor- 
tality, 730 
problem of city Supply, 347-349 
products and typhoid fever, 133 
raw, bactericidal power of, 380 

feeding of, to older children, 360 
scarlet fever and, 389 
septic sore-throat and, 115, 389 
sterilization of, in the home, 198-199 
store, bacteria in, 353-354 
effect on infants, 356 
supply and sanitary surveys, 229 
means to ensure proper, 363 
methods of public sanitary con- 
trol, 368-384 
testing of, in bacteriological labora- 
tory, 365-368 
used in infant feeding, bacterio- 
logical investigation of, 350-360 
vehicle of infection, 218 
Mind, serenity of, relation of, to health, 

516-518 
Mineral salts in food, 481 
Mites, 594 
Molluscum contagiosum, treatment of, 

in school children, 707 
Mongolianism, 782 
Morbidity statistics, 845-847 
Moron, 780, 783, 786-788, 789 

case histories of, 792-794 
Mortality among users of alcohol, 489 
rates, increase in deaths from 

chronic organic diseases, 478 
records, uses of, 820-821 
relation of, to overweight, 483 
statistics, 820-833. See also Death 
statistics 
method of collecting, 835-836 
Mosaic law, 735 

Mosquito, culex and anopheles, 157 
destruction of, 592 

breeding places, 448-449 
prevention and control and sanitary 

surveys, 236 
relation of, to tropical disease, 592 
screening against, 448 
Mountain sickness, 243 
Mouth, disinfection of discharges from, 
189 
hygiene, 510-513 

spray as disseminator of disease, 258 
Mov:'^g pictures, use of, in public health 

education, 750, 751-752 
Mucous membranes, entrance and growth 

of microorganisms on, 22 
Mumps in camp, 531 
incidence of, 130 
incubation period of, 130 



INDEX 



875 



Mumps, infectious agent of, 130 
methods of control of, 130-131 
mode of transmission of, 130 
period of communicability of, 130 
source of infection of, 130 

Munition manufacture, poisons in, 623 

Muscular disuse as factor influencing 
physical deterioration, 472 

Mushroom poisoning, 394 



N 



Nails. See Finger-nails. 

Nationality, effect of, on mortality rate, 

Nativity of parents, influence of, on 

birth-rate, 817 
Natural ventilation, 265-266 
Negri bodies, 161 
Neurasthenics in the army, 521 
Neuritis as a result of focal infection, 497 
Neuropathic ancestry, charts illustrat- 
ing, 781 
Newspapers in health education. 740- 
746 
use of, by rural health officer, 578 
New York State Commission on Ventila- 
tion, 245-246, 249-252, 253-255, 256- 
257, 260, 266, 273, 274, 275, 277 
Nitrates in water, 412 

use of, as food preservatives, 338 
Nitrites in water, 411-412 
Nitro-aromatic poisoning, chronic, 625 
pathology of, 624-625 
symptoms of, 625 
treatment of, 625-626 
poisons, classification of, 624 
Nitrogen in air, 240 

as albuminoid ammonia in water, 

411 
as free ammonia in water, 411 
total, in water, 411 
Nitrous fumes poisoning, pathology of, 
623-624 
symptoms and treatment 
of, 624 
Non-residents, effect of, on mortality 

rate, 829-830 
Nose, disinfection of discharges from, 

189 
Notification in epidemic fighting, 221 
Nuisances, duties of health officer, 560 
Nurse and prenatal work, 682-683 

home visits bv, effect on infant mor- 
tality, 690-^91 
in industrial plants, 665-667 
public health, activities of, 574-575 

duties of, 572-573 
school, follow-up visits, 711 
visiting in rural districts, 573 
Nursing, public health, in rural districts, 

572-575 
Nutrition, disorders of, due to lack of 
vit amines, 325 



Occupation, data of, in death certificates 
836 
effect of, on mortality rate, 828 
Occupational diseases, 608-627 

classification of causes of, 60S 
industrial hygiene and, 604 
statistics, 847-848 
Odors, 244-246 
in air, 242 
Offices, temperature of, 284, 285 
! Open-air classes in schools, 722 
J school rooms, 266 

; Ophthalmia neonatorum and midwives, 
■ 670^671 

Opsonic action, technic of demonstration 
of, 52-54 
of measurement of, 52-54 
determinations, applications' of, 54 
index, method of Wright, 54 
Opsonins, 50-51 

Ordinances, rural health, 565-566 
Organic effluvia, effects of, 244-246 
Organization of rural health department, 

557-572 
Outdoor air, value of, 278 
living, 500 
sleeping, 500-501 
Overcrowding, effect of, 297 

on infant mortality, 831 
Overeating, effect of, 319-320 
Overweight, danger of reducing, by 
means of strenuous exercise, 483 
menace of, 482-488 
Oxalic acid in food, 329 
Oxygen in air, 240-241, 242 
consumed by water, 413 
dissolved in water, 413 
physiological effects of, 240-243 
Oysters, diseases transmitted by, 390 
Ozone in air, 240 

sterilization of water, 423 



Palmer dust sampler, 290-291 
Pancreas, diseases of, as a result of focal 

infection, 497 
Pandemic, 209 
Paraphenvlene diamine test for peroxide 

in food," 339 
Parasites, animal, in raw vegetables, 393 
Parasitic organisms in food, 394-396 

skin diseases, 506 
Paratyphoid fever, incidence of, 139 
infecting agent of, 139 
methods of control of, 139 
oysters and, 390 
period of communicability of, 

139 
source of infection of, 139 
the soldier and, 551 
in meat, 390, 391 
Paresis. See General paralysis. 



876 



INDEX 



Pasteur treatment by mail, L65 
effects of, 165 

for rabies, 163-166 
immunity from, 165 
intensive method of, 165 
original method of, 164 
results of, 165 
Pasteurization of milk in home, 199-200, 
necessity for supervision, 

382 
reasons for and against, 380 
t emperature necessary, 380 
preservation of food by, 333 
Pediculosis, treatment of, in school chil- 
dren, 707 
Pellagra, a deficiency disease, 325 
relation to diet, 735 
result of unbalanced diet, 320, 394 
Pennsylvania Department of Labor and 

Industry, report of, 603 
Periodic medical examinations, 473, 474, 

498 
Peroxide, use of, as food preservative, 

338-339 
Personal cleanliness, necessity for, in 
industry, 645-646 
rules of, 473 
of soldiers, 540 
hygiene, 471-498 
Perspiration, 502 

Petterson-Palmquist apparatus, 282 
Pfeiffer phenomenon, 44 
Phagocytic cells, 49-50 
activity of, 51 
fixed, 49 
motile, 49 
Phagocytosis, 49-58 

mechanism of, 51-52 
Phosphate, acid, use of, in checking fly 

nuisance, 439 
Physical apathy as factor influencing 
physical deterioration, 472 
defects in school children, extent of, 

708 
deterioration, factors influencing, 

472-473 
examination of bathers, 462 
strain as factor influencing physical 
deterioration, 472 
in industrial occupations, 655 
work, effect of temperature on, 250 
Physician and health department, 567 
in the army, 545-551 
personnel of, 546 
ratio of, 545 
in industrial plants, 665-667 
reports of death by, 835 
role of, in mental hygiene, 775-776 
in public health education, 752 
in rural health work, 557 
Pike's Peak, effect of atmosphere, 243 
Pin maps, 854 
Pit ot tube, 280 
Pityriasis versicolor, 173 
Plague bacillus in cerebrospinal menin- 
gitis, 97 



Plague, immunity in, 166 
incidence of, 166 
incubation period of, 167 
infectious agent of, 166 
methods of control of, 167 
mode of transmission of, 166 
period of communicability of, 167 
quarantinable disease 798 
source of infection of, 166 
types of, 166 
Plant poisons, 393-394 
Plenum ventilation, 269 

in industrial plants, 634 
Plumbing inspection, 458 

traps, 455-457 
Pneumococcus in acute lobar pneumonia, 
85 
in cerebrospinal meningitis, 97 
Pneumonia, acute lorjar, incidence of, 85 
incubation period of, 86 
infectious agent of, 85 
methods of control of, 86 
modes of transmission of, 

86 
source of infection of, 85 
as cause of infant death, 831 
failure to control, 724 
precipitin reaction in, 42-43 
Poisoning, anilin, 609-610 

by meat and fish, 391-393 
from plant foods, 393-394 
mushroom, 394 
potato, 394 
Poisons, animal, similar to toxins, 26 
drugs and metabolic, influencing 

physical deterioration, 473 
microbal, 26 

in munition works, 623-627 
other than microbal, precipitins for, 

43-44 
relation to personal hygiene, 473 
vegetable similar to toxins, 26-27 
Poliomyelitis, incidence of, 98-99 
incubation period of, 99 
infectious agent of, 99 
methods of control of, 99 
mode of transmission of, 99 
overcrowding and, 297 
period of communicability of, 99 
source of infection of, 99 
Polluted water, 406 

interpretation of laboratory 
findings, 408 
Pollution of soil, 400-401 

of water, 407 
Polyneuritic psychosis, 759 
Ponds as sources of water supplies, 404 
Population, changes in, importance of, 
in sanitary surveys, 224-225 
density of, effect of, on mortality 

rates, 828 
enumeration of, 808-811 
estimation of, 811 

errors in, 848-849 
geometrical method of, 851-852 
Posters in public health education, 748 



INDEX 



877 



Postnatal conditions, effect of, on infant 

mortality, 831 
Posture relation to health, 509-510 
Potable water, 406 
Potato poisoning, 394 
Poultry, adulteration of, 344 

effect of cold storage on, 332 
Poverty, effect of, on infant mortality, 

831 
Precipitation of sewage by chemicals, 

431-432 
Precipitin antigen, nature of, 43 
reaction, 42-44 
anthrax, 43 
pneumococcus, 42-43 
practical applications of, 42-43 
Precipitins, 42-44 

development of, 42 
for other than microbal poisons, 43 
nature of, 42 
Premature old age, factors influencing, 

472-473 
Prematuritv as cause of infant mortality, 

678 
Prenatal care of mothers, value of, 732 
conditions, effect of, on infant mor- 
tality, 831 
work, 682-683 
Pre-school age day nurseries, 698-700 
health centers, 698 
importance of, 697 
child, supervision of, 697-700 
Preservaline, 336 

Preservation of foods. See Foods. 
Preservatives in milk, detection of, 364 
Pressure niters, 420 
Privy, objections to, 428 
sanitary, 428 
vaults, 297-299 

methods of cleanliness and dis- 
infection, 191 
typhoid fever and, 298 
Prostitutes, feeble-mindedness among, 

790 
Prostitution and venereal diseases, 151 
Protein foods, 310, 480-481 
Protozoa, adaptation of, to certain tis- 
sues, 18-19 
Psychoneuroses, 764-765 
Psychrometers, 285-288 
Ptomains, 29, 391 

Puberty, mental training at, 771-772 
Public health education, 736 

cooperating and assisting 

agencies, 756 
dispensaries and, 754-755 
feature campaigns and, 754 
history of, 736 
lectures, qualifications of 

lecturer, 750 
newspapers and, 740 
physician and, 752-754 
in schools, 738 
suggested reading, 755 
use of exhibits, 748-750 
of lectures, 750-751 



Public health education, use of moving 
pictures, 750-751 
of periodic publica- 
tions, 746 
of posters, 748 
Publications, periodic, in public health 

education, 746 
Publicity in public health, 577-579 
Puerperal septicemia, 671 
Pulse-rate, effect of temperature on, 249 
Pure food and drugs act, 341-343 
Purification of water, methods of, 418 
Pyroligneous acid, use of as food pre- 
servative, 338 
Pyorrhea, 510-513 



Q 



Quarantinable diseases, 798 
Quarantine, maritime. See Maritime 
quarantine. 



Rabies, 158-166 

antirabic serum, 166 

diagnosis of, 161 

disposal of dogs suspected to be 
suffering with, 162 

incidence of, 158 

incubation period of, 159 

local treatment of bite, 163 

methods of control of, 162 

pasteur treatment of. See Pasteur 
treatment. 

symptoms of, 159 
in dog, 160 
in man, 160 

transmission of, 159 
Race, effect of, on mortality rate, 827 
Rat control, 600 

extermination, 601 

and sanitary survey, 236-237 
Ration, definition of, 534 

emergency, 537 

field, 537 

garrison, 534 

importance of fresh foods in 327 

reserve, 536-537 

travel, 537 
Rations, 534-537 

types of, 534 
Rats, breeding of, 599 

classification of, 599 

food habits of, 600 

general habits of, 600 

migration of, 599 
Recirculation, 276-277 
Recreation, value of, in personal hygiene, 

515-516 
Recruit, physical and mental require- 
ments, 519-520 

training of, 520 
Red Cross Association, American Na- 
tional, 550 



878 



INDEX 



Reduction of garbage, 437 
Refrigeration , 33 1-332 
Refuse, disposal of, in camp, 541 
Regimental aid station, 546 
Registration area, 834-835 

of birth. See Birth registration, 
of deaths, 833-845 

history of, 833-835 
Regulations of health board, special, 566 

housing, 444-445 
Relative humidity, 241, 242 

determination of, 285-288 
physiological effects of, 255-257 
in school rooms, 288 
Relaxation, value of, in personal hygiene, 

515-516 
Report of an epidemic, 222 
Reservoirs, impounding, 404 
Resistance to disease, effect of atmos- 
pheric temperature on, 253 
of infectious organisms, 24 
Respiratory disease, as cause of infant 
death, 831 
effect of temperature upon, 253 

of ventilation upon, 274 
influence of, upon infant mor- 
tality, 680 
diseases among soldiers, 551 

transmitted through swimming 
pool, 460 
infections, epidemiology, 217 
Retreat, medical service during, 550 
Re vaccination, 121 

Rheumatism, acute and chronic, result 
of focal infection, 497 
of unbalanced diet, 320 
Rickets as result of unbalanced diet, 320, 

325 
Rinderpest, 321 
Ringworm, 172 

treatment of, in school children, 707 
Rocky mountain spotted fever, incidence 
of, 171 
incubation period of, 171 
infectious agent of, 171 
methods of control of, 171 
mode of transmission of, 171 
period of communicability 

of, 171 
source of infection of, 171 
Rodents, role of, in spread of tropical dis- 
eases, 598 
Rooms, disinfection of, 190 
Rotheln. See German measles. 
Rubella. See German measles. 
Rubeola. See Measles. 
Ruehle tube, 291, 292 
Rural public health work, 555-582 



Salicylic acid, detection of, in food, 337 

as food preservative, 337 
Salt a food constituent, 328-329 

use of, in food preservation, 333 



i Salting, a food preservative, 331 
Saltpeter, use of, as food preservative, 
^ 338 

Sand fly and tropical disease, 593 
Sanitary code, prosecution for violation 
of, 566-567 
rural, 565-567 
survey of camp, scheme for, 552, 554 
fly breeding, 236 
health budget, 237-238 

department, 237 
of rat extermination, 236 
of water supply, 417 
surveys, 224r-238 
charities, 235 
commerce and its effect on 

sanitation, 224 
disposal of excreta, 230-231 
garbage disposal, 234 
general death-rates, 225-226 
housing conditions, 232-233 
industries and industrial haz- 
ards, 231-232 
infant mortality, 227-229 
medical school inspection, 234 
milk supply, 229-230 
mosquito prevention and con- 
trol, 236 
population changes, 224-225 
progress of sanitation, 224 
public health laboratory, 235 
publicity and education, 236 
sanitation of markets, 233-234 
school sanitation, 233 
sources of information, 224 
specific death-rates, 226-227 
street sanitation, 234 
water supply, 229 
train, 548 
Sanitation, effect on mortality rate, 
828 
in epidemic fighting, 222 
of swimming pools, 459-470 
Saranac Lake Sanatorium, 240 
Scabies, in school children, treatment of, 

707 
Scalp, care of, 505 
Scarlatina. See Scarlet fever. 
Scarlet fever, 127-129 

conveyed by milk, 389 
immunity, 128 
incidence, 127 
incubation period of, 128 
infectious agent of, 127 
methods of control of, 128-129 
mode of transmission of, 127 
period of communicability of, 

128 
source of infection of, 127 
Schick reaction, 103-109 
control tests, 104 
details of technic, 104 
at different ages, 106-107 
interpretation of, 106 
negative in cases of suspected 
diphtheria, 108 



INDEX 



879 



Schick reaction, permanence of negative 
reaction in persons developing 
natural immunity, 107-109 
positive, 103 
practical value of, 106 
pseudoreaction, 104 
School and mental hygiene, 771 

child, examination of, for physical 
defects, 708-715 
follow-up visits by nurse, 711 
frequency of physical examina- 
tion, 709 
hygiene of, 713-714 
mode of physical examination, 

710-711 
physical defects, 709 
records of physical examina- 
tion, 712 
standards of health, 709 
houses, methods of cleaning and dis- 
infecting woodwork, 191 
hygiene, 715-722 
blackboards, 717 
books, 717 
cloakrooms, 720-721 
desks and chairs, 717-718 
lighting, 717 

location of buildings, 715-716 
maintenance of buildings, 722 
size of classrooms, 716 
special classes, 722 
toilets, 721 
ventilation, 718-720 
walls, 717 

washing and drinking facilities, 
721 
medical inspection and hygiene, 
700-722 
emergency treatment, 708 
history of, 700-701 
organization, 702-703 
part of health program, 701 
routine, 704 

inspection, 708 
types of, 703-704 
sanitation and sanitary surveys, 233 
Schoolrooms, open air, 266 
sanitation of, 705 

temperature and respiratory dis- 
ease, 254 
ventilation of, 266-268, 274-276 
Schools, closing of, during epidemic of 
influenza, 77 
epidemics, 706 
contagious diseases in, 705-706 
control of contagious eye and skin 

diseases, 706-708 
health education in, 738 
Screens in sewage treatment, 430-431 
Scurvy, 324, 326 

relation to diet, 735 
result of unbalanced diet, 320 
Sea-sickness on troop transports, 529 
Sedimentation in sewage treatment, 431 
Segregation of passengers and crew in 
maritime quarantine, 801 



Seminal vesicles, infection of, as factor 
influencing physical deterioration, 473 
Septic sore-throat, 115 

conveyed by milk, 389 
incubation period, 115 
infectious agent of, 115 
methods of control of, 115 
mode of transmission of, 115 
period of communicability of, 

115 
source of infection of, 115 
tank, 432 
Serum agglutinating, titration of, 33 
reaction, 66, 67 

prevention of, 67-68 
treatment of developed shock, 
68 
Sewage, chemical precipitation of, 431 
definition of, 428 
disposal, 428-436 

in camp, 541-543 
dilution method, 428-429 
duties of health officer, 560 
sanitary surveys and, 230-231 
in tropics, 588, 589 
irrigation, 435 

methods of artificial treatment, 429 
objects of artificial treatment, 429 
sterilization of, 435 
Sewer gas, 458 
Sewerage, house, 455-458 
Sex, effect of, on mortality rate, 826 
Shellfish, pathogenic bacteria in, 390 

typhoid fever and, 133 
Shoes, fitting of, to soldiers, 525 

personal hygiene and, 507 
Sinuses, infection of, as a factor influenc- 
ing physical deterioration, 473 
Skin, care of, 502 

diseases, contagious, control of, in 
schools, 706-708 
infectious, caused by fungi, 172 
incubation period of, 173 
infectious agents of, 173 
methods of control of, 173 
mode of transmission of, 

173 
period of communicability 

of, 173 
source of infection of, 173 
entrance and growth of micro- 
organisms, 21-22 
parasitic diseases of, 506 
reactions, practical value of, 69-70 
Sleep, necessity for, 516 

outdoor, 500-501 
Sleeping balconies, arrangement of, 501 
Slow sand niters, 418-419 
Sludge, activated, 434-435 

disposal, 435 
SmaUpox, 115-124 

disinfection of, 123-124 

incidence of, 116 

isolation of, 123 

prevention and control of, 117-124 

registration of cases of, 123 



sso 



INDEX 



Smallpox, transmission of, 116 

vaccination. See Vaccination. 
Smoke, volatile matter in, as food pre- 
servative, 336 
Soapsuds solution for cleaning house and 

sickroom, 186 
Social conditions, effect on infant mor- 
tality, 831 
factors, as causative agents in dis- 
ease, classification of, 724 
Sociologic and economic aspects of dis- 
^ ease, 723 
Soda solution for cleaning house and 

sickroom, 186 
Sodium hypochlorite disinfection of 

swimming pools, 464 
Soil, 397-402 

absorption of odors by, 401 
bacteria in, 398-399, 400, 401-402 
biological properties of, 400 
chemical properties of, 398-399 
classification of, 397 
fertilizing constituents of, 398 
formation of, 397 
physical properties of, 399-400 
pollution, 400-401 

diseases in tropics, 595 
temperature of, 400 
typhoid fever and, 133 
Soldier, diseases of, 551 

inspection of person and equipment, 

523 
value of hygienic training, 525 
Sore-throats among soldiers, 551 
Spices, use of, as food preservatives, 336 
Spitting in industrial plants, 651-653 
Springs as sources of water supplies, 404 
Sputum as mode of tramsmission in 
tuberculosis, 90 
from consumptives, disinfection of, 
189-190 
Standard methods for water analysis, 409 
Starch test for peroxide in food, 339 
Starchy foods, 480 
Stations for slightly wounded, 548 
Statistical errors due to difference in 
classification, 850-851 
from compounding death-rate, 

850 
from paucity of data, 849 
percentages, 849-850 
population, 848-849 
to be avoided, 848-851 
tables illustrative, 822, 824-825, 832, 
853 
Statistics, definition of, 805 
epidemiological, 219-221 
industrial hygiene, 607-608 
marriage. .See Marriage statistics, 
morbidity. See Morbidity statistics, 
occupational. See Occupational sta- 
tistics, 
of stillbirths. See Stillbirths, 
vital. See Vital statistics. 
Statutes, health, 557 
Steam disinfecting chambers, public, 196 



Stereopticon, use of, in public health 

education, 750-751 
"Steri-lab," 424-426 
Sterilization by chemicals, 177 
of milk in home, 198-199 
preservation of food by, 333 
Stillbirths, causes of, 820 

certificate of N. Y. City Health De- 
partment, 819 
rates, methods of computing, 820 
statistics, 818-820 
Stomach, entrance and growth of micro- 
organisms in, 22 
Streets and sanitary surveys, 234 
Streptococci in air, 258 
Streptococcic sore-throat. See Septic 

sore-throat. 
Streptococcus in cerebrospinal menin- 
gitis, 97 
Subcutaneous tissues, entrance and 

growth of microorganisms, 22 
Sugar-cane, use of, in food preservation, 

333 
Sugars as food, 480 
Sulphites, use of, as food preservatives, 

339 
Sulphur dioxide in disinfection of house, 
195—196 
of vessels, 802-803 
vs. formaldehyde gas for disin- 
fection, 196 
Sulphurous acid in food, 329 
detection of, 340 
use of, as food preservative, 339 
Survey plan for camp, 552-554 
for rural district, 581 
sanitary. See Sanitary survey, 
ventilation, points to be covered in, 

279 
of water supply, 417 
Susceptibility to disease, 211, 212, 213 
Swimming pools, bacteriologic standards, 
467 
construction and equipment of, 

460-462 
control of bathers in, 462 
dilution in, 463 
diseases transmitted through, 

459-460 
laws governing, 468 
management of water in, 462 
refiltration of water in, 463 
sanitation of, 459-470 
standards for legislation, 468 
Syphilis, 146-147 

cause of death, 843 

of infant death, 833 
of general paralysis, 758 
cerebral, 759 
effect on offspring, 760 
factor influencing physical deteriora- 
tion, 473 
incidence of, 146 
incubation period of, 146 
infectious agent of, 146 
methods of control of, 146 ? 149-153 



INDEX 



881 



Syphilis, mode of transmission of, 146 
period of communicability of, 146 
relation of, to feeble-mindedness, 

788, 791 
source of infection of, 146 



Table utensils, disinfection of, 190 
Tables, statistical, illustrative, 822, 824- 

825, 832, 853 
Tabulations, mechanical methods of, 845 
Tags, identification, 545 
Tapeworm, 396 
Teeth, care of, 497, 510-513 

infection of, as a factor influencing 
physical deterioration, 473 
Temperature of air, 242 

atmospheric, 583 

automatic control of, 264, 271 

determination of, 283-285 

effect of, on infants, 349, 355, 362 
upon efficiency, 250-253 

resistance to disease, 253 

of factories, 285 

influence of, on growth of bacteria 
in milk, 349 

of offices, 284, 285 

physiological effects of, 246-250 

of rooms, 499 

of schoolrooms, 276, 285 
Tenements, model, 445 
Tentage, 531-532 
Tents, shelter, 532 
Terminal disinfection, 184 
Tetanus following vaccination, 122 

incidence of, 153 

incubation period of, 154 

infecting agent of, 154 

methods of control of, 154 

mode of infection of, 154 

period of communicability of, 154 

source of infection of, 154 
Tetrachlorethano poisoning, 627 
Texas fever and meat inspection, 321 
Thermal standards of ventilation, 263 
Thermostats, value of, 264-265, 276 
Ticks, 594 
Tinea circinata, 172 

favosa, 173 

versicolor, 173 
Titration of agglutinating serum, 33 
Tobacco, 491-496 

economic aspect of, 495 

effects of, 491-495, 496 
Toilets, in industrial plants, 650 

in schools, 721 
Tonsils, infection of, as factor influencing 

physical deterioration, 473 
Towel supply in industrial plants, 649 

in schools, 721 
Toxicity of microorganisms, increase and 

decrease of, 20 
Toxin, extracellular, 26 

hypersensitiveness, 64-65 



Toxin, intracellular, 26 
Trachoma, incidence of, 87 

incubation period of, 88 

infectious agent of, 87 

management of, in school children, 
707 

methods of control of, 88 

mode of transmission of, 88 

period of communicability of, 88 

source of infection of, 88 
Transports, troop, capacity of, 529 
Trauma, mental and physical as a factor 
influencing physical deterioration, 473 
Trench fever, 859 
Trenches, hygiene of, 543 
Trichina spiralis, 394-396 
Trichinosis, incidence of, 174 

incubation period of, 174 

infectious agent of, 174 

methods of control of, 174 

mode of transmission of, 174 

period of communicability of, 174 

source of infection of, 174 
Troops, feeding of, while on march, 526 

movement of, 525-527 

moving, equipment of, 530 

personal hygiene of, 540 

rate of marching of, 526 

shelter of, 530-532 

transportation of, by rail, 527-529 
by water, 529-530 

water supply of, 537-540 

on march, 526-527 
Tropical hygiene, 583-601 
Tubercle bacillus in dust, 257 

human and bovine types, 89 
in milk, 383 
in water, 417 
Tuberculin, use of, 94 
Tuberculosis, 88-95 

among soldiers, 551 

beginning of antituberculosis move- 
ment, 737 

bovine in man, 91-92, 386-388 

causes other than tubercle bacillus, 
724 

deaths from, 88 

disinfection of sputum, 189-190 

dried and moist sputum, 90 

duty of attending physician, 570 

early detection of, in school children, 
706 

economic aspect of, 88 

etiology of, 89 

factor influencing physical deteriora- 
tion, 473 

housing, and, 294-295 444, 726 

immunity against, 93 

incidence of, 88 

incubation period, 95 

individual susceptibility, 93 

in industry, 607 

infected meat, 390 

influence of prosperity on death-rate, 
89 

ingestion infection, 91 



882 



INDEX 



invalidism due to, 727 
methods of control, 95 
mineral dust and, 259 
mode of infection, 88-90, 94 

of transmission, 94 
period of communicability, 95 
public health nurse and, 574 
pulmonarv, mortality rate in New 
York City, 726 
occupation as causative factor 
of, 726 
relation of, to income, 727 
social and economic aspects of, 

725-728 
source of infection of, 94 
special classes for tuberculous chil- 
dren, 722 
Typhoid bacillus in cerebrospinal menin- 
gitis, 97 
in milk, 383 
in water, 415, 416 
fever, 131-139 

carriers, 133-134 
diagnosis of, 134-136 
endemic, 131 

factor influencing physical de- 
terioration, 473 
from raw vegetables, 393 
gastro-intestinal disease pre- 
ceding outbreak of, 205 
ice-borne, 408 
immunity, 136 
incidence of, 131 
incubation period of, 136 
infectious agent of, 131 
methods of control of, 137-139 
mode of transmission of, 131 
oysters and, 390 
period of communicabilitv of, 

136 
privy and, 298, 428 
relation of typhoid carrier to 

milk infection, 388-389 
soldier and, 551 
transmitted through swimming 

pool, 459 
in tropics, 597 
vaccination in, 136-137 
water-borne, 407-417 
residual, 131 
Typhus fever, economic aspects of, 735 
quarantinable disease, 798 



Ultra-violet light disinfection of swim- 
ming pools, 464r-465 
ray in sterilization of water, 423 
Uniform, service and dress, 522 
U. S. Navy, heat stroke in, 248-249 
Urethra, infection of, factor influencing 

physical deterioration, 473 
Urinals, 455 



Urine, bacteriological examination of, in 
typhoid fever, 135 
disinfection of, 189 
Urticaria, relation to food, 394 



Vaccination, 117 

age at which it should be performed, 

119 
claims for, 122 

complications and dangers of, 121 
in epidemic fighting, 122 
immunity to smallpox acquired 

through, 121 
law, 119 

methods of, 118-119 
normal course of, 120, 121 
preparation of virus for, 117-118 
results of, 122 
revaccination, 121 
successful, 120, 121 
technic of, 120 
Vaccines in influenza, 74, 84-85 

in prevention of acute lobar pneu- 
monia, 86 
of typhoid fever, 136-137 
Vaccinia, generalized, 122 
Varicella. See Chickenpox. 
Variola. See Smallpox. 
Vegetables, canned, aduleration of, 345, 
346 
part of dietary, 318 
raw, infection from, 393 
typhoid fever and, 133 
Venereal diseases, 144-153 
alcohol and, 152 
among soldiers, 551 
control of, 149-153 
economic aspects of, 144 
education and publicity and, 

152-153 
effects of, 144-145, 502 
forbidden occupations and, 151 
incidence of, 144, 146, 147-148 
individual prophylaxis in. 153 
influence of, on birth-rate, 817 
necessity for treatment of, 150 
prostitution and, 151-152 
registration of, cases of, 151 
relation of, to housing condi- 
tions, 300 
in sea ports, 724 
transmitted through swimming 
pool, 460 
Ventilation, 239-292 
balance system, 635 
choice of method, 274-276 
cooling, artificial, 277-278 
distribution of air, 272-274 
drafts and dust, 631 
exhaust system, 634 
Fairfield system, 266-268 
heating and, 263-265 
in houses, 296, 448 



INDEX 



883 



Ventilation in industrial plants, 627-636 
King system, 267 
mechanical, 268-274, 633 
natural, 265, 266 

cases in which it is unsatisfac- 
tory, 632 
devices to assist, 628 
objects and standards, 261-263 
operation factor, 278 
plenum system, 634 
practical methods, 261-278 
recirculation, 276-277 
relation to personal hygiene, 499 
of schoolrooms, 718-720 
surveys of, 279-280 
testing of equipment, 279-282 
value of outdoor air, 278 
Vessels, diagnosis of, in maritime quar- 
antine, 799-800 
disinfection of, 802 
inspection of, 798-799 
types of, met with in maritime quar- 
antine, 796-798 
Vinegar, use of, in food preservation, 

333-334 
Violet-ray, use of, in food preservation, 

340 
Virulence of infecting organisms, 211, 
212, 213-214 
of microorganisms, increase and 
decrease of, 20 
variation in degree of, 19, 20 
Virulins, 71-72 
Vision, defective, relation of, to personal 

hygiene, 513 
Vital statistics, 805-858 

books of reference, 808 
definition of, 805 
essential requisites of, 808 
history of, 807 
purpose of, 805-807 
rules of, usage of, 806-807 
Vitamines, 320-321, 324-326, 481 
diseases due to lack of, 324-325 
effect of, on drying food, 331 
experimental evidence for, 325 
fat soluble, 325 
mode of action of, 325 
sources of, 325 
water soluble, 325 



W 



Wage earners, number of, 602-603 

annually sick, 603 
Waste, collection of, 436-437 
disposal, 436-442 

in U. S. Army cantonments, 
439-442 
Wastes, classification of, 436 
Water, amount, required by troops, 537 
analysis, sanitary survey, 417 
bacteriological examination of, 415- 
417 



Water, bacteriological standards for 
swimming pools, 467 
borne typhoid fever, 131 
chemical analysis, 410-414 

reaction of, 410 
closets, 454-455 

methods of cleanliness and dis- 
infection, 191 
on troop transports, 529-530 
color of, 410 
consumption of, 406 
disinfection of, in swimming pools, 

463-467 
as food, 481 
for troops, 537-540 

on march, 526-527 
ground, 404-406 
ice and, in rail transportation of 

troops, 528 
microscopic examination, 414-415 
odors and taste, 410 
organic matter in, 410 
physical examination, 409-410 
polluted, relation to transmission of 

disease, 407-409 
purification in field, 424-426 

for troops, 538-540 
rain, 403 
refiltration of, in swimming pools, 

463 
sanitary analysis of, 409-417 
softening of, 410 

source of, for swimming pools, 462 
supplies, classification of, 405 
dual, 407 

duties of health officer in rela- 
tion to, 560 
historical note on, 403 
purification of, 417-418 
their purification and, 403-427 
treatment of, 417-423 
in tropics, 584 
supply, drinking cups, and, in indus- 
trial plants, 647-649 
in houses, pipes and fixtures, 

453-455 
housing and, 299 
sanitary survey and, 229 
in schools, 721-722 
sources of, 403-405 
on troop transports, 529 
surface, 404 
total solids in, 410 
turbidity of, 410 
vapor, 241 

vehicle of infection, 218 
Weather, 583 

Weight and height, average, tables of, 
486 

influence of, on vitality, 484-485 
of recruit, 520 
Wells, artesian, 405 
deep, 404 
shallow, 404 
Wet-bulb temperature, 248 
Whooping-cough, incidence of, 129 



SM 



INDEX 



\\ 'hooping-cough, incubation period of, 
129 
infectious agent of, 129 
methods of control of, 129-130 
mode of transmission of, 129 
period of communicability of, 

129 
source of infection of, 129 
Widal reaction, 32, 38-39 
Window ventilation, 266-268, 274-276 
Windows in factory, arrangement and 
construction of, 638-640 
saw-tooth, 628-629 
Wood alcohol. See Methyl alcohol. 
Woolsorters' disease. See Anthrax. 
Work, effect of speeding up and over- 
time on, 654 
monotonous, effect of, 654-655 
physical effects of, 515 
Worry as cause of disease, 517 
Wounded, care of, on battlefield, 544 
search for, after battle, 550 



Xerophthalmia, relation of, to diet, 735 



Yellow fever, incidence of, 156 
incubation period of, 156 
infectious agent of, 156 
methods of control of, 156-158 
mode of transmission of, 156 
mosquito and, 592 
period of communicability of, 

156 
quarantinable disease, 798 
source of infection of, 156 



Z 



Zinc poisoning. See Brass. 









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